bluuebunny/crossref_metadata_2025 huggingface dataset:
A Novel Use of Arthroereisis in the Adult Flat Foot
Authors: Dega Raman , Peek Anna C. , Malagelada Francesc , Clark Callum I.
Published: October 2016

Category:

Hindfoot

Introduction/Purpose:

The use of an arthroereisis screw is well described in the paediatric population for the correction of flexible flat feet. Here we present a case comparison series involving the use of an arthroereisis screw to augment reconstruction in adult patients with Tibialis Posterior Insufficiency.

Methods:

All patients (36 feet in 34 patients) underwent flexor digitorum longus transfer, reefing of the spring ligament and a translational medialising calcaneal osteotomy. In 23 cases the reconstruction was augmented with an arthroereisis screw (Kalix, Integra), which was removed 6 months later in all cases. The mean age was 58 years and most patients were female. Weight bearing radiographs were taken after removal of the implant and assessed using previously published parameters. Patients were evaluated at follow up using validated functional outcome questionnaires (MOXFQ, EQ-5D and a health VAS).

Results:

One patient in the group without augmentation went on to have a triple fusion 13 months after reconstruction. In both cohorts the calcaneal pitch was raised, Meary’s angle decreased, the medial cuneiform height increased and the talonavicular coverage angle improved post-operatively compared to pre-operative measurements (p < 0.05, Wilcoxon Signed Rank tests). There was a trend towards better radiographic correction in the augmented group and the difference in correction of the talonavicular coverage angle was statistically significant (p < 0.05, Students T test). There was however no difference between the MOXFQ, EQ-5D and heath VAS scores between the two groups at mean follow up of 4 years.

Conclusion:

We conclude that the use of an arthroereisis screw is a promising adjunct to conventional reconstruction in tibialis posterior insufficiency.
A Prospective Cohort Study of Symptomatic Venous Thromboembolic Events in Foot and Ankle Trauma
Authors: Blanco Jose A. , Brocklesby Gemma , Mangwani Jitendra
Published: October 2016

Category:

Trauma

Introduction/Purpose:

The incidence of Venous Thromboembolism (VTE) and the balance of risks and benefits associated with chemical thromboprophylaxis in foot and ankle trauma are controversial, and much less investigated than in hip and knee surgery. A recent systematic review showed a low VTE rate in foot and ankle surgery (0-0.55%), but with an increased incidence in foot and ankle trauma, the highest in TA rupture and surgery. This study compares the 90-day VTE rates of 3 cohorts of patients: Group 1: TA ruptures managed in a full weight bearing (FWB), functional, Vacoped™ protocol over an 8 week period; Group 2: Stable ankle fractures managed in NWB below knee casts for 6 weeks; Group 3: Unstable or displaced ankle fractures managed with surgery and NWB below knee casts for 6 weeks.

Methods:

The data was extracted from two prospectively collected databases, one for the acute TA ruptures between March 2010 and December 2014, and one for ankle fractures from October 2013 to April 2014. These datasets were cross validated with the hospital VTE database. All patients were risk assessed at the time of presentation to the hospital. Selective chemical thromboprophylaxis was prescribed for patients with the previous history of VTE and patients who were deemed high-risk on VTE assessment. 90-day incidence of symptomatic VTE was drawn from the hospital radiology database.

Results:

Group 1: Overall VTE rate of 4.9% at a mean of 16.1 days. 3 Pulmonary Embolism (PE) and 11 Deep Vein Thrombosis (DVT). Total number of 283 patients. Group 2: Overall VTE rate of 2.2% at a mean of 33.4 days. 5 DVT. Total number of 227 patients Group 3: Overall VTE rate of 3.0% at a mean of 37.2 days. 1 PE and 5 DVT. Total number of 199 patients. Symptomatic VTE presents significantly earlier in acute TA rupture than ankle fracture patients (p=0.002)

Conclusion:

Although the overall incidence of VTE in foot and ankle trauma is low., there is a relatively higher incidence of VTE in patients with acute TA ruptures. This is, in spite of recent early weight bearing regimens. This study also shows that occurrence of symptomatic VTE in patients with Acute TA rupture happens much sooner compared to the ankle fracture patients. Although the exact reason for this difference in time of presentation of VTE is unknown, it may be due to de-functioning of the calf muscle pump immediately after the acute TA rupture.
An Algorithm to Assist the Surgical Decision Making in the Operative Management of the Cavovarus Foot
Authors: Grice John E. , Willmott Henry , Taylor Heath P.
Published: October 2016

Category:

Hindfoot

Introduction/Purpose:

The cavovarus foot is a complex deformity caused by muscle imbalance, soft-tissue contracture and secondary bony abnormality. It is a combination of hindfoot, midfoot and forefoot deformity and the decision making process for surgical management can be difficult. The process of deciding which combination of procedures is required is often poorly understood. We present an algorithm to assist with this decision making.

Methods:

We have analyzed a single surgeon's experience of cavovarus foot correction, from a consecutive series of 60 patients over 6 years, to develop an algorithm to guide operative decision making. Cases included cavovarus deformity secondary to cerebral palsy, Frie-dreich's ataxia, Charcot Marie Tooth disease, post-traumatic contracture, post-cerebrovascular accident, iatrogenic post-surgery and physiological cavus. We have taken a systematic appr oach to each component of the deformity in order to generate the algorithm.

Results:

To assist in rationalizing the traditional ‘a-la-carte’ approach, our algorithm describes what we believe are the indications for a variety of surgical interventions, including soft tissue contracture release, osteotomies of the hindfoot, midfoot and forefoot, tendon transfer and soft tissue balancing, and arthrodesis. We detail the decision making process for each surgical option and give the reasons for each decision. We have also reviewed the available literature on this topic, to produce an evidence-based and useable means of surgical planning.

Conclusion:

The surgical decision making process in the management of the cavovarus foot is complex. We believe that this algorithm, based on extensive personal experience and up-to-date published evidence, provides a clear and proven framework on which surgical decision making can be guided and justified.
Bone Reconstitution With Synthetic Bone Graft Material for Osseous Defects in Revision Total Ankle Arthroplasty
Authors: Beuchel Matthew W. , Brage Michael
Published: October 2016

Category:

Ankle Arthritis

Introduction/Purpose:

Various treatments have been suggested for the treatment of periarticular cysts in revision total ankle arthroplasty including autograft and allograft bone grafting, polymethylmethacrylate cement, and revision to ankle or tibiotalocalcaneal arthrodesis. This study investigated the rate of osseous reconstitution following treatment with a unique calcium phosphate-calcium sulfate blend.

Methods:

A retrospective review of all revision total ankle arthroplasty procedures over a 3 year period was performed. 37 patients were identified that had utilized the calcium phosphate-calcium sulfate blend for the treatment of osseous defects. Data on graft location, volume, infection rate, bone reconstitution rate, and further revision procedures were collected. Plain radiographs were used to determine osseous reconstitution, qualified as bony trabeculae present with no lytic area remaining. Patient's average age was 66 years old, revision performed an average of 9.5 years after primary arthroplasty, with an average of 503 (range 99-1333) days of follow up.

Results:

Grafting of 23 tibial, 23 talar, 7 fibular, and 5 calcaneal bone defects were undertaken. All patients had Agility implants at time of primary arthroplasty. 16 patients had retention of Agility components, with 21 being revised to Inbone 2 implants. An average of 8.25 ml of material was used. Complete bone reconstitution was noted in 24 patients (65%). Incomplete or no bony healing was noted in 9 talus, 2 tibias, and 2 fibulas. Further revision was performed or offered to 7 patients for continued symptoms(19%). No seromas or excessive wound drainage was noted.

Conclusion:

Grafting of osseous defects for total ankle arthroplasty with a fully synthetic calcium sulfate and calcium phosphate mixture is an effective technique. Caution should be used in its use for patients with talar subsidence, as these have higher rates of failure likely due to its diminished blood supply and smaller surrounding structural support. provide significant long-term structural support. It should not be depended to
Buttress Plating versus Anterior-to-Posterior Lag Screws for Fixation of the Posterior Malleolus
Authors: Bennett Chase , Behn Anthony , Daoud Adam I. , Dikos Gregory , Bishop Julius , Sangeorzan Bruce
Published: October 2016

Category:

Trauma

Introduction/Purpose:

The preferred method of fixation for posterior malleolus fractures remains controversial, and practices vary widely among surgeons. The purpose of this study was to compare anterior-to-posterior lag screws to posterior buttress plating for fixation of posterior malleolus fractures in a cadaveric model.

Methods:

Posterior malleolus fractures were created in seven pairs of fresh frozen cadaveric ankles. One specimen in each pair was randomly assigned to fixation with either two anterior-to-posterior lag screws or a one-third tubular buttress plate without supplemental lag screws. Each specimen was then subjected to cyclic loading from 0% to 50% of body weight for 5,000 cycles followed by loading to failure. Failure was defined as 1 mm of axial displacement.

Results:

The buttress plate group showed significantly less peak axial displacement at all time points during cyclic loading. Permanent axial displacement was significantly less in the buttress plate group beginning at cycle 200 (figure). There were no significant differences between the two groups during load to failure testing.

Conclusion:

Posterior malleolus fractures treated with posterior buttress plating showed significantly less displacement during cyclical loading compared to fractures fixed with anterior-to-posterior lag screws. Surgeons should consider these findings when selecting a fixation strategy for these common fractures. these biomechanical findings. Further research is warranted to investigate the clinical implications of
Comparison of Fixed and Unmounted Digital Radiography System in Foot and Ankle Practice
Authors: Grimes J. Speight , Ackerman Mitchell
Published: October 2016

Category:

Other

Introduction/Purpose:

Digital radiography (DR) is rapidly replacing conventional and computer radiography. The configuration of DR can vary widely. Two common types of DR seen in outpatient settings are the fixed mounted systems with a motorized arm that contains the imaging plate or a unmounted imaging plate with either a tether or wireless connection to the main console. This study compared the efficiency of the two systems in a foot and practice.

Methods:

Two practices that routinely obtain weight bearing foot and ankle radiographs were identified. One used a fixed mounted DR system and the other a unmounted tethered DR system. An observer timed 50 sequential weight bearing radiographs of the foot or ankle at each facility. The time began when the patient was ready for the examination until the final image had been obtained.

Results:

The mean time for a foot or ankle image was 224 seconds (SD 93 seconds) for the fixed mounted system and 122 seconds (SD 29 seconds) for the unmounted system. The time difference was statistically significant (P < 0.001).

Conclusion:

The use of unmounted imaging plates more closely follows traditional techniques for weight bearing radiographs of the foot and ankle. Fixed mounted systems require special equipment and techniques to accommodate the mounting arm. These special needs almost double the time required to obtain the weight bearing radiographs. It is more efficient for foot and ankle practices to use systems with an unmounted imaging plate.
Comparison of Fusion and Complication Rates in Patients with Primary Open Ankle Arthrodesis
Authors: Barg Alexej , Lyman Mikayla , Morris S. Craig , Saltzman Charles L.
Published: October 2016

Category:

Ankle Arthritis

Introduction/Purpose:

In the last decades, different surgical techniques with various approaches and fixation methods have been described for ankle arthrodesis. Tibiotalar arthrodesis can be performed with or without distal tibiofibular fusion. The objectives of this retrospective study were to compare (1) demographics, (2) surgical techniques, (3) postoperative fusion rates, and (4) postoperative complication rates in patients with primary open tibiotalar arthrodesis with vs. without distal tibiofibular fusion.

Methods:

Between March 2002 and November 2014, 322 primary open ankle arthrodeses were performed at our institution. There were 183 male and 139 female patients with a mean age of 56.0 ± 14.0 years (18.0-88.8). The mean weight, height, and body mass index (BMI) were 90.0 ± 20.4 kg (46-168), 172.9 ± 11.4 cm (147-208), and 30.0 ± 5.7 kg/m2 (18.9-54.9), respectively. Both patient groups were compared with regard to demographics including gender, weight, height, BMI, ASA classification, smoking, alcohol use, and comorbidities. The surgical technique has been analyzed in both groups including surgical approach, main fixation type, and allograft/autograft use. Finally, fusion rate and time to complete osseous fusion were analyzed. Complication rates including wound complications, deep vein thrombosis/pulmonary embolism, and any secondary procedures were described in both groups. The mean time to final follow-up was 36.7 ± 26.7 months (12.0-150.4).

Results:

214 had a combined distal tibiofibular fusion, while 108 did not. The most common surgical approach was lateral and anterior in patients with and without distal tibiofibular fusion, respectively (P < 0.001). The main fixation type was different between groups, with the most common technique being screws for patients with tibiofibular fusion, and plates in those without (P < 0.001). Autograft and allograft were used significantly less frequently in patients without distal tibiofibular fusion. The rate of osseous union was comparable in both groups with 92.2% and 93.0% in patients with and without distal tibiofibular fusion, respectively (P = 0.675). The incidence of wound and thrombembolic complications was similar in both groups.

Conclusion:

The osseous union rates and complication rates were comparable in both patient groups, with and without distal tibiofibular fusion.
Effect of Blood Flow of the Metatarsal Head with Hallux Valgas after Minimally Invasive Distal Linear Metatarsal Osteotomy
Authors: Minokawa So , Yoshimura Ichiro , Naito Masatoshi , Kanazawa Kazuki , Hagio Tomonobu
Published: October 2016

Category:

Hindfoot

Introduction/Purpose:

Distal first metatarsal osteotomies are recommended for surgical treatment of mild to severe hallux valgus (HV) deformities. Angthong et al. reported that minimally invasive distal linear metatarsal osteotomy (DLMO) exhibited good outcomes, with no major complications. However, avascular necrosis of the metatarsal head following a distal osteotomy has been reported, because an aggressive plantar cut can disrupt the soft tissue plantarly, thereby disrupting the blood supply of digital arteries. The purpose of this study was to evaluate the in vivo blood flow of the pre- and post-osterotomy metatarsal head in patients with HV using laser Doppler flowmetry (LDF).

Methods:

Between April and November 2015, DLMO was performed on seven patients with HV. The patients comprised one male and four females, with a mean age at surgery of 43.4 (21–62) years. The primary surgical indications for DLMO were all levels of severity of possible manual correction in patients with foot pain. The patients were placed in the supine position, and without a tourniquet, a 1.5-cm skin incision was centered over the medial aspect of the first metatarsal neck. A 2.0-mm Kirschner wire was inserted manually from the wound to the medial side of the hallux using a retrograde technique. Under direct vision, the Kirschner wire was introduced into the medullary canal of the first metatarsal shaft. Blood flow measurements of the pre- and post-osteotomy first metatarsal head in the seven patients were performed by LDF (ALF21 N; ADVANCE Co., Tokyo, Japan). The probe was touched to the first metatarsal head. The blood flow measurements were repeated three times, and the mean values were calculated.

Results:

On preoperative plain radiographs, the mean hallux valgus angle was 38.0° (range: 22.4–45.8°), and the mean intermetatarsal angle was 17.0° (range: 10.4–21.9°). The mean pre- and post-DLMO systolic blood pressure at the time of the measurements was 87.3±7.76 and 88.1±8.25 mmHg, respectively (P=0.85). The mean pre- and post-DLMO blood flow rate was 1.71±0.68 and 1.66±0.49 ml/min/100 g, respectively (P=0.90).

Conclusion:

Steven et al. reported that a distal osteotomy can lead to avascular necrosis of the metatarsal head, because an aggressive plantar cut can disrupt the soft tissue plantarly, thereby disrupting the blood supply of digital arteries. However, we found that blood flow of the pre- and post-osteotomy metatarsal head was present in all patients examined, with no significant difference in the blood flow rates of the metatarsal head before and after DLMO. Based on the present results, it is possible to avoid major complications, such as avascular necrosis of the metatarsal head, because DLMO is minimally invasive and involves less release of the soft tissue.
Factors Affecting the Formation of Post-Traumatic Subtalar Arthritis Following the Intra-Articular Calcaneal Fracture
Authors: Angthong Chayanin
Published: October 2016

Category:

Hindfoot

Introduction/Purpose:

The present study was performed to prospectively follow up the arthritic changes of subtalar joint following the intra-articular calcaneal fractures in 38 patients.

Methods:

A total of 38 patients with intra-articular calcaneal fractures were prospectively studied with a mean follow-up as 17.4 months. Conventional fixations were performed in 27 patients by several surgeons. Arthroscopic-assisted reduction and internal fixations were performed in 11 patients by a single foot-ankle fellowship trained surgeon. Baseline data, including postoperatively radiographic alignment, arthritic changes, osteochondral lesion characteristics via modified Outerbridge classification and locations of lesions at calcaneal/talar side, and arthroscopic treatment procedures, were collected. Statistical analyses were performed to compare the prevalence and characteristics of the osteochondral lesions between the group with or without post-traumatic arthritic changes.

Results:

Based on the interpretation of radiographic parameters by a single foot-ankle fellowship trained surgeon, there were 8 patients (21.1%) showed the arthritic progression. Acceptable reduction (fracture step/gap < 2 mm) was found in 31 patients (81.6%) in overall. No significant difference of the quality of fracture reduction was found among the groups (none, mild, significant progression of arthritis). In subgroup analysis in patients with arthroscopic-assisted reduction and internal fixations, there was no significant difference of the prevalence of osteochondral lesions among the groups.

Conclusion:

The prevalence of post-traumatic subtalar arthritis was found in X-rays around one in 5 patients with the intra- articular calcaneal fractures in short-term follow-up. No definitive factors affecting arthritic changes were found in this study. Further investigation is needed to identify these factors in longer term of follow-up.
Functional Range of Motion Following Total Ankle Replacement
Authors: Marks Richard M. , Huntington William P. , Brennan Stephen M.
Published: October 2016

Category:

Ankle

Introduction/Purpose:

Total ankle replacement (TAR) is an accepted option for the surgical treatment of end-stage ankle arthritis. The potential benefit of TAR over ankle arthrodesis is the preservation of motion following TAR, however, little is reported concerning the true gain of range of motion (ROM) following TAR. This study compares standard goniometric measurements with two radiographic measurement techniques, as well as reports the changes in ROM following TAR.

Methods:

Between 2007 and 2012, 48 TAR in 46 patients were performed by a single surgeon, using a modern, fixed-bearing design. 40 patients (19 female, 21 male) had complete clinical and radiographic follow-up greater than 2 years postoperatively. Mean age at surgery was 73 +/- 9 years. Patients were evaluated with pre-operative and 2 year post-operative goniometric weight- bearing exam, as well as plantarflexion (PF) and dorsiflexion (DF) lateral radiographs. Radiographs were analyzed using the talocrural method, which measures the angle between the long axis of the tibia and talus, as well as a “full foot” method, which utilizes the angle created by the long axis of the tibia and medial cuneiform. The difference between the PF and DF angles was considered the arc ROM. Means were compared using a Wilcoxon signed-rank test to evaluate the significance of the difference between means (p < 0.05)

Results:

Mean arc range of motion increased from pre-operatively to post-operatively for all methods analyzed. Goniometric arc ROM significantly increased from 27.1° +/- 9.4° to 39.6° +/- 14.0°, a difference of 12.5° +/- 13.6° (p< .001). Talocural arc ROM significantly increased from 22.7° =/- 11.9° to 27. 8° +/- 10.2°, a difference of 5.1° +/- 11.2° (p=.006). Full foot arc ROM increased, but not significantly, from 46.7° +/- 15.5° to 48.8° +/- 12.6°, a difference of 2.6° +/- 11.2° (p=0.154). There was no significant difference observed between the mean gain in arc ROM between the two radiographic measurements (p=.062). However, the mean gain in arc ROM for goniometry significantly differed from both the talocural and full foot radiographic methods (p=.012 and p= .001, respectively).

Conclusion:

In this study, goniometry measurements tended to overestimate motion gained following TAR when compared to 2 radiographic measurement techniques. Interestingly, the talocrural method, which evaluates the ankle in isolation, was almost double the motion noted with the full foot method (5.1° vs. 2.6°) The full foot method may take into consideration the compensatory changes through the hindfoot and midfoot to account for ankle arthritis, that is alleviated post-TAR, hence, more modest gains in “full foot” arc ROM.
Hyaluronic Acid Injection After Failed Arthroscopic Microfracture in Osteochondral Lesion of the Talus
Authors: Park Yoo Jung , Park Kwang Hwan , Suh Jae Wan , Hwang Yeokgu , Shim Dong-Woo , Han Seung Hwan , Lee Jin Woo , Choi Woo Jin
Published: October 2016

Category:

Ankle

Introduction/Purpose:

The optimal treatment for symptomatic osteochondral lesion of the talus (OLT) after failed arthroscopic microfracture has been a controversial issue. The use of viscosupplementation for treatment of OLT has been gradually increasing. The hyaluronic acid (HA) injection is believed to play an important role in reducing pain and inflammation, and promoting tissue repair. The purpose of this study is to evaluate the clinical outcomes of intra-articular HA injection for the patients with failed arthroscopic microfracture in OLT.

Methods:

This study included 12 patients who received three weekly injections of intra-articular HA after arthroscopic microfracture for OLT between October 2014 and October 2015. Five men and seven women were included in this study. The average age at the time of injection was 41 years (range, 19-63 years). All patients had recurrent pain for at least 6 months after the index surgery. The patients were followed for 6.1 months (range: 5.0-7.0). At each visit, the efficacy of HA injection was evaluated by a Visual Analog Scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score and Foot and Ankle Outcome Score (FAOS) pain subscale. In addition, subjective satisfactions were assessed by the Alexander scale.

Results:

The mean period from the arthroscopic microfracture to the intra-articular HA injection was 26.5 months (range: 6.0- 87.0). Mean VAS decreased from 6.7 ± 1.1 at pre-injection to 2.4 ± 1.6 at post-injection six weeks (p < 0.001), 3.1 ± 1.5 at three months (p = 0.002) and 3.8 ± 2.3 at six months (p = 0.02). Mean AOFAS score improved from 61.0 ± 9.1 at pre-injection to 85.3 ± 11.3 at post-injection six weeks (p < 0.001), 82.9 ± 10.4 at three months (p < 0.001) and 80.4 ± 13.8 at six months (p = 0.001). Mean FAOS pain subscale also improved from 53.2 ± 4.2 at pre-injection to 71.1 ± 9.4 at post-injection six weeks (p < 0.001), 66.7 ± 7.2 at three months (p = 0.001) and 64.4 ± 9.5 at six months (p = 0.036). According to the Alexander scale, there were 58.3% (7/12) good, 25.0% (3/12) fair, and 16.7% (2/12) poor results at post-injection six months. There was no adverse effect.

Conclusion:

In this study, we found that the main improvement in clinical outcomes occurred during the first six weeks and significantly maintained until at least three or six months. We believe that the HA injection could be a useful treatment option after failed arthroscopic microfracture in OLT.
Limb Preserving Surgical Treatment of Osteomyelitis in the Foot
Authors: Waldecker Ute
Published: October 2016

Category:

Other

Introduction/Purpose:

Osteomyelitis of the foot and ankle is a challenging problem. In the literature the outcome of limb preserving surgical treatment is characterized by a high percentage of osteomyelitis recurrence and revision surgery. The aim of this study was to evaluate the outcome of limb preserving surgery of osteomyelitis in the foot.

Methods:

From 2013 to 2015 42 patients with a mean age of 66 years underwent surgical treatment of osteomyelitis in the foot. Patients who were treated with amputations were excluded from the study. In all patients initial surgery with debridement, bone resection, bone biopsy, jet lavage and gentamycin inlay was performed. Depending on the clinical findings revision surgery and finally resection arthroplasty or arthrodesis followed. All patients had an antibiotic treatment for 6 weeks. The location of the osteomyelitis, the applied surgical procedure, the number of surgical procedures, the number of postoperative complications, the recurrence rate of osteomyelitis, the recurrence rate of foot ulceration and the histological findings were documented.

Results:

Forty-two patients (28 diabetics) were included in the study. The mean follow up was 19.7 months. The location of osteomyelitis showed the following distribution: minor toes (24%), great toe (19%), metatarsals (33%), midfoot (13%), hindfoot (11%). Twenty-six patients showed a foot ulceration. Bone biopsy confirmed chronic osteomyelitis in 28, acute osteomyelitis in 7 patients. After control of wound infection surgery consisted of a resection arthroplasty in 14 patients, an arthrodesis in 12 patients. The mean number of surgical procedures was 3. The complication rate was 14.2%. Osteomyelitis recurrence was found in 4 patients. Patients treated with a resection arthroplasty showed no ulcer recurrence however in 50% of the patients who had been treated with a MTP1 or IP 1 arthrodesis a recurrent ulcer was seen( p < 0.05).

Conclusion:

Limb preserving surgical treatment of osteomyelitis in the foot shows a high complication rate. Resection arthroplasty of the forefoot in comparison to arthrodesis provides significantly better results with less ulcer recurrence.
Most Readmissions Following Ankle Open Reduction Internal Fixation are Unrelated to Surgical Site Issues
Authors: Fu Michael C. , Schairer William W. , Demetracopoulos Constantine A. , Ellis Scott J.
Published: October 2016

Category:

Trauma

Introduction/Purpose:

Ankle fractures are commonly-sustained injuries, and frequently require open reduction internal fixation (ORIF). It is generally a safe and effective surgical procedure, however, as quality-based reimbursement models become increasingly affected by readmissions within thirty days, it is important to determine causes and risk factors for patients to be readmitted after discharge.

Methods:

Patients that underwent ORIF for ankle fractures were identified from the prospectively-collected American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2013 to 2014. Baseline demographics, comorbidities, and fracture characteristics (open vs. closed, location of fracture such as lateral malleolus, medial malleolus, bimalleolar, or trimalleolar) were determined. Modified Charlson Comorbidity Index (CCI) was used as a measure of overall comorbidity burden. Rates of thirty-day adverse events and readmissions were determined, as well as the causes for readmission. Multivariable logistic regression analyses were performed to identify risk factors significantly associated with having any adverse events and being readmitted within thirty days of surgery.

Results:

5,056 ankle ORIF patients were included. 167 (3.3%) were open fractures. The rate of any postoperative adverse event was 5.2%. There were 127 readmissions, with 116 (91.3%) being unplanned readmissions. Of the 116 unplanned readmissions, 49 (42.2%) were for reasons related to the surgery or surgical site, with the most common causes being deep surgical site/hardware infection (12.9%), superficial site infection (11.2%), and wound disruption (6.9%). Most readmissions were for reasons unrelated to the surgical site (51.7%), including cardiac disorders (8.6%), pulmonary disorders (7.8%), and neurologic/psychiatric disorders (6.9%). With multivariable logistic regression, the strongest risk factors for readmission were history of pulmonary disease (Odds Ratio [OR] 2.29), ASA ≥ 3 (OR 2.28), and open fracture (OR 2.04, all p < 0.05). (Figure 1)

Conclusion:

Postoperative readmissions following ankle fracture ORIF are important to consider in this era of quality-based hospital reimbursement models. In this cohort of 5,056 ankle ORIF cases, 2.5% of patients were readmitted within thirty days, with 51.7% of all unplanned readmissions due to causes unrelated to the surgery or surgical site. This suggests that close medical follow-up with non-orthopaedic providers may be necessary after discharge. To assist clinicians in preoperative risk stratification, predictors of readmission were history of pulmonary disease, increased ASA class, and open fracture. Higher bundled reimbursements may be justified for cases with these risk factors.
Optimum Insertional Direction of the Suture Anchor in Arthroscopic Lateral Ankle Ligament Repair
Authors: Yoshimura Ichiro , Hagio Tomonobu , Noda Masahiro , Minokawa So , Fukuda Nobuyoshi , Kanazawa Kazuki , Naito Masatoshi
Published: October 2016

Category:

Arthroscopy

Introduction/Purpose:

The gold standard for chronic lateral ankle ligament injury is ligament repair via the modified Broström- Gould procedure. Recently, lateral ankle ligament repair has been performed arthroscopically. This requires the insertion of one to three suture anchors in the fibula from anterior to posterior via the accessory portal. It is important to insert the suture anchors completely into the fibula bone. Because the distal fibula is tapered and has a fossa on the posterior surface, unfavorable insertional direction of the suture anchor can lead to complications such as inadequate suture anchor stability or friction between the suture anchor and the peroneus tendons. This study aimed to investigate the distance between the insertion point of the suture anchors and the posterior surface of the fibula on computed tomography (CT) images.

Methods:

Twenty ankles from 16 patients who had undergone three-dimensional CT scans for foot or ankle disorders without deformity of the fibula were assessed (10 male, 10 female; mean age, 32 years; age range, 12–78 years). The shortest distance from the insertion point of the suture anchor to the deepest point of fossa/the top of the convex of fibula was measured on the axial planes tilting from the longitudinal axis of the fibula at 90°, 75°, 60°, and 45°. We also measured the distance from the insertion point of the suture anchor to the posterior surface of the fibula, in a direction parallel to the sagittal plane of the lateral surface of the talus on the axial planes tilting from the longitudinal axis of the fibula at 90°, 75°, 60°, and 45°.

Results:

The posterior fossa was observed in all cases on the 90° and 75° images. The distance from the insertion point to the posterior surface of the fibula in a parallel direction was 15.6 mm at 90°, 18.0 mm at 75°, 21.5 mm at 60°, and 24.8 mm at 45°. The posterior points in a parallel direction were located on the posterior fossa in 40% of cases at 90°, in 10% at 75°, and in 0% at 60° and 45°.

Conclusion:

We suggest that the suture anchor should be directed from anterior to posterior at an angle of less than 60° to the longitudinal axis of the fibula, parallel to the lateral surface of the talus, in order to avoid passing through the fibula.
Pathogenesis of Fifth Metatarsal Stress Fractures in College Soccer Players
Authors: Sugimoto Kazuya , Kumai Tsukasa , Kurokawa Hiroaki , Isomoto Shinji , Tanaka Yasuhito , Fujitaka Kohei , Taniguchi Akira
Published: October 2016

Category:

Sports

Introduction/Purpose:

The pathogenesis of fifth metatarsal stress fractures remains uncertain. We hypothesized that physical characteristics and environmental factors, which have received limited attention in the literature thus far, might be involved in the development of such fractures. To test our hypothesis, we performed a medical checkup and a survey of the living environment of athletes in college soccer teams, and subsequently, we investigated the existence of fifth metatarsal stress fractures, and examined the differences between the injury group and the non-injury group.

Methods:

The survey and measurements were conducted in 273 male athletes from the same college soccer team between 2005 and 2013. A medical checkup, comprising assessment of stature, body weight, body mass index, arch height ratio, toe-grip strength, quadriceps angle, leg-heel angle, functional reach test, one-leg standing time with eyes closed, straight leg raise test, finger-floor distance, heel-to-buttock distance, ankle joint range of motion, and general joint laxity test, and a questionnaire survey were performed once a year. A survey was conducted at the time of injury that resulted in fifth metatarsal stress fractures. The study participants were separated into an injury group and a non-injury group, depending on whether they had a fifth metatarsal stress fracture. The measurement items and survey items were compared, and the association between the presence or absence of injury and the measurement items was analyzed.

Results:

Toe-grip strength was significantly weaker in the injury group, compared with the non-injury group, suggesting that a weak toe-grip is associated with fifth metatarsal stress fracture (p < 0.05). In addition, injury on the non-dominant leg was more frequent in the fifth metatarsal stress fracture injury group (p < 0.05). Between-group comparisons of the other items showed no statistically significant differences.

Conclusion:

The association between weak toe-grip strength and fifth metatarsal fracture suggests that a weak toe-grip may lead to an increase in the load applied onto the lateral side of the foot; this may cause mechanical stress on the bone. In addition, the effect of the non-dominant leg on the fifth metatarsal bone may need to be studied further.
Posterior Talar Shifting in Mobile-Bearing and Fix-Bearing Total Ankle Replacement
Authors: Usuelli Federico G. , Manzi Luigi , Maccario Camilla
Published: October 2016

Category:

Ankle Arthritis

Introduction/Purpose:

Sagittal implant malalignment after total ankle replacement (TAR) has been considered to be a possible cause for premature implant failure. In a prior study, the change of the tibiotalar ratio (T-T ratio) over time in TARs was assessed in an unconstrained, three component implant. A significant increase in the T-T ratio between 2 and 6 months after surgery (from 34.6% to 37.2%) was documented. This variation of the talar position in the sagittal plane may be due to the presence of an inlay between the tibial and the talar components.

Aim:

The aim of this study was to compare the translation of the talus in TARs performed with an unconstrained, three-component design (Hintegra, Newdeal, Lyon, France; Integra, Plainsboro, NJ), and those performed with a semi-constrained, two- component design (Zimmer Trabecular Total Ankle, Zimmer, Warsaw, IN).

Methods:

The study included 71 consecutive patients (71 ankles) who underwent TAR with the Hintegra implant and 24 consecutive patients (24 ankles) who received the Zimmer implant between May 2011 and December 2014. The most common indication for TAR was post-traumatic arthritis (80.3% and 75.0% in the Hintegra group and in the Zimmer group, respectively). Patients were assessed clinically and radiologically preoperatively (T0), at 6 months (T2) and 12 months (T3) post-surgery. There was also a radiological assessment 2 months after surgery (T1).

Results:

The comparison of the T-T ratio between the two groups and over time indicated an interaction between time and group, therefore the changes of the T-T ratio with time were affected by the implant type factor (p < 0.0001). The changes of the post-operative T-T ratio over time were not significant in the Zimmer group (35.7%±6.7% at T1, T2, and T3; p=1.0 for each pairwise comparison). In the Hintegra group, the T-T ratio at 2 months (34.4%±5.5%) was significantly different to the T-T ratio at 6 months (37.0% ± 5.8%; p < 0.0001). The American Orthopaedic Foot & Ankle Society (AOFAS) score significantly increased from pre-op to 6 months post-surgery in both the Hintegra group (53.3±16.0 at 6 mos; p < 0.0001) and the Zimmer group (76.8±7.0 at 6 mos; p < 0.0001). There was no statistical difference in the preoperative scores (Hintegra: 32.7 ± 12.8; Zimmer: 34.6 ± 11.9; p=0.5347).

Conclusion:

The significant antero-posterior translation of the talus documented only in the cohort receiving the unconstrained, three-component implant may have associated with, and produced by the presence of the mobile bearing interface between the polyethylene insert and the tibial prosthesis.
Primary vs. Revision Ankle Arthrodesis
Authors: Barg Alexej , Lyman Mikayla , Morris S. Craig , Saltzman Charles L.
Published: October 2016

Category:

Ankle Arthritis

Introduction/Purpose:

The current standard treatment for failed ankle arthrodesis is a revision ankle arthrodesis. However, there is limited literature addressing postoperative outcomes in patients with revision tibiotalar arthrodesis. The objectives of the retrospective study were to compare (1) demographics, (2) surgical technique, (3) postoperative fusion rates, and (4) postoperative complication rates in patients with primary vs. revision tibiotalar arthrodesis.

Methods:

Between March 2002 and November 2014, 455 ankle arthrodeses were performed in our institution. There were 234 male and 221 female patients with a mean age of 55.6 ± 15.1 years (18.0-88.8). The mean weight, height, and body mass index (BMI) were 90.3 ± 21.3 kg (46-218), 172.8 ± 13.6 cm (147-208), and 30.2 ± 6.3 kg/m2 (18.9-61.7), respectively. Both patient groups were compared with regard to demographics including gender, weight, height, BMI, ASA classification, smoking, alcohol use, and comorbidities. The surgical technique has been analyzed in both groups including surgical approach, main fixation type, allograft/autograft use, and use of bone morphogenic protein. Finally, fusion rate and time to complete osseous fusion were analyzed. Complication rates including wound complications, deep vein thrombosis/pulmonary embolism, and any secondary procedures were described in both groups. The mean time to final follow-up was 38.3 ± 27.4 months (12.0-150.4).

Results:

There were 385 and 70 patients with primary and revision arthrodesis, respectively. Demographics and comorbidities were comparable in both groups. All revision surgeries were open procedures, while 63 of 385 primary ankle arthrodeses were performed arthroscopically. The most common main fixation type in patients with primary ankle arthrodesis was a screw construct, while plates were most common for revisions (P < 0.001). The use of autograft was comparable in both groups (P = 0.886), however allograft was used more frequently in the revision arthrodesis group (P < 0.001). The rate of osseous union was comparable in both groups with 90.4% and 91.4% in patients with primary and revision arthrodesis, respectively (P = 0.735). The complication rate was comparable in both groups.

Conclusion:

The osseous union rates and complication rates were comparable in both patient groups, with primary and revision ankle arthrodesis.
Prospective, Randomized, Controlled, Comparative Effectiveness Trial Examining Healing, of Acellular-Reticular Human-Dermis Versus Standard Care in Treatment of Diabetic Foot Ulcers
Authors: Zelen Charles M. , DiDomenico Lawrence , Serena Thomas , Li William W. , Kaufman Jarrod , Carter Marissa J. , Galiano Robert , Orgill Dennis P.
Published: October 2016

Category:

Diabetes

Introduction/Purpose:

One sequitur of prolonged diabetes is the development of diabetic foot ulcers (DFUs), which are often complicated by lower extremity amputation (LEA). The annual incidence of DFUs and LEAs calculated from the Medicare population is approximately 6% and 0.4% respectively. Many acellular dermal matrices have been shown to successfully heal these wounds. In this study, we examined a novel, human, acellular reticular dermis with an open, porous, uniform framework aseptically processed to retain endogenous matrix protein versus standard of care in non healing diabetic foot wounds.

Methods:

This study was a multicenter, randomized controlled trial in which diabetic patients having at least one non-healing neuropathic foot ulcer that failed at least 4 weeks of documented conservative care with adequate blood flow and a lack of renal failure were screened for a 2-week period. Those meeting inclusion and exclusion criteria, after 2-weeks of offloading and moist wound care if the diabetic foot ulcer (DFU) failed to reduce in area by 20% were randomized 1:1 to standard of care (SOC) or human acellular dermal tissue (HADT) applied weekly plus SOC for up to 12 weeks

Results:

At 6 weeks, 65% of the HADT–treated wounds had healed (13/20) compared to 5% (1/20) of the wounds that received SOC alone (adjusted p=.00028). At 12 weeks, 80% of the HADT–treated wounds (16/20) had healed compared to 20% (4/20) of the DFUs in the SOC group (adjusted p=.00036). Mean time to heal within 12 weeks was 39.6 days for the HADT group compared to 77.0 days for the SOC group (adjusted p=.00014). There was no incidence of increased adverse or serious adverse events between groups, nor adverse events related to the graft. The mean and median costs to closure in the HADT group were $1475.00 and $963.00, respectively, per healed wound

Conclusion:

These findings demonstrate that weekly application of acellular human reticular dermis is an effective treatment for non-healing diabetic foot wounds. Wound-size-specific pieces may allow for decreased cost to closure and wastage.
Relationship of Sesamoid Position and Other Radiographic Measurements in Hallux Valgus
Authors: Yeo Eui Dong , Oh Seong Rok , Lee Young Koo , Choi Young Suk , Kim Ki Chun
Published: October 2016

Category:

Midfoot/Forefoot

Introduction/Purpose:

Many radiographic measurements have been developed and used for evaluating hallux valgus, but their relationships have not been clearly established. The purpose of the present study was to investigate the relationship and reliability of sesamoid position and other radiographic measurements in hallux valgus.

Methods:

We included 180 patients(mean age 52 years; 18 males and 162 females) with weightbearing plain radiograph. In anteroposterior view, hallux valgus angle, intermetatarsal angle, distal metatarsal articular angle, proximal phalangeal articular angle, hallux interphalangeal angle, sesamoid subluxation and metatarsophalangeal congruency were measured. In lateral view, Meary angle(tarso-1st metatarsal angle) was measured. 3 trained observers measured. Correlations among the radiographic measurements were analyzed. Relationship of sesamoid position and other radiographic measurements were evaluated using ANOVA or Fisher’s exact test.

Results:

The sesamoid subluxation had the correlation with the hallux valgus angle (p < 0.001), intermetatarsal angle (p < 0.001) and metatarso-phalangeal joint congruency (p < 0.001). As the sesamoid subluxation grade increased, the metatarso-phalangeal joint congruency was non-congruent joint. In intraobserver reliability, the hallux valgus angle showed the highest ICC value (0.989; 95% CI, 0.984–0.992)

Conclusion:

we suggest that the measurements of sesamoid subluxation in assessments of hallux valgus deformity may be helpful for operation and degree of metatarsophalangeal congruency.
Results of Single incision Hallux Valgus Surgery
Authors: Qasim Sultan N. , Elzubeir Lee , Bhatia Maneesh
Published: October 2016

Category:

Bunion

Introduction/Purpose:

Soft tissue release is an integral part of Hallux Valgus surgery and is traditionally performed through an additional dorsal first web space incision. We performed a review of Hallux Valgus correction with Scarf +/- Akin osteotomy using single medial incision with lateral release performed through the same incision.

Methods:

The study included 202 feet operated by a single surgeon between July 2009 and July 2014. Average age of patients at the time of operation was 60 years +/- 14. Patient satisfaction survey was conducted at the time of study. Patients with minimum follow up of 12 months post surgery were included in this study. The average follow up at the time of study was 45+/- 18 months. Pre-operative and final post-operative radiographic data was collected for Hallux Valgus angle, Intermetatarsal angle, Distal Metatarsal Articular Angle and Medial Sesamoid Position. The average Mean radiological follow up duration was 6.7 months.

Results:

Mean Hallux Valgus Angle improved from 33.2 to 15.6 degrees, Intermetatarsal angle improved from 14.4 to 7.8 degrees, Distal Metatarsal Articular Angle improved from 17.6 to 9.8 and Medial Sesamoid Position improved from 3 to 1 [p < 0.05 for each variable]. Response rate was 78% (Very satisfied 69%, Satisfied 14%, Satisfied with reservation 11%, Dissatisfied 6%). There was no correlation of any preoperative or postoperative radiographic measure with satisfaction grade. Two patients had intraoperative fracture with no long term sequelae. No patient required revision procedure.

Conclusion:

Single medial incision surgery for Scarf +/- Akin Osteotomy for Hallux Valgus Correction is a simple, safe and effective technique with very high satisfaction. The results are comparable to, if not better that, traditional two-incision surgery thus questions requirement of a second dorsal first web space incision.