bluuebunny/crossref_metadata_2025 huggingface dataset:
Reducing potential for needle-stick injuries in the operating room
Authors: Saltzman Eliana , Scott Daniel
Published: September 2018

Category:

Other

Introduction/Purpose:

The CDC estimates that at least 385,000 sharps injuries occur annually among US healthcare workers, which may even be as high as 800,000. Traditionally, wound closure demands the OR scrub tech to pre-load suture needles onto needle drivers that are presented to the surgeon and then passed back once the needle has been used. With frequent passing of contaminated needles, needle-stick injuries occur commonly in the OR. Operative Armour (Sharp Fluidics®, LLC) incorporates a novel needle trap that enables surgeons to independently self-secure and self-dispense suture needles during closure (Fig. 1). We hypothesized that the use of Operative Armour as compared to the standard technique of sequentially passed needles would reduce the number of sutures passes.

Methods:

Three cadaveric specimens were dissected in this study. A 12 cm long incision was made through an anterior and posterior approach to the ankle joint in each specimen. The incisions were cross-hatched at 1 cm intervals with a surgical marking pen to indicate closure points. Two layers, subcuticular and skin, were closed. All three participants were orthopedic foot and ankle fellows at our institution. All wound closures were done with interrupted suture technique using 2-0 vicryl pop-off suture (Covidien), containing 5 needles per pack. Group A used traditional suture passing from the scrub tech vs the Operative Armour in Group B. The participants completed three trials for each group first through the anterior and then through the posterior approach. Outcome measures included number of needle passes, dropped needles, and closure time.

Results:

Suture passes averaged 52±8.9 for Group A compared to 5.3±0.7 in Group B (p<0.05). There were 24 needle handoffs in Group A, in Group B only three suture packs were passed. Overall closure time was 16:35±0.2 minutes in Group A and 16:33±0.1 minutes for Group B (p= 0.8). No needles were dropped in either group. For the anterior incision, suture passes averaged 56±11.3 in Group A compared to 5.6±0.9 in Group B (p<0.05). The closure time for Group A was 16:51±0.2 minutes and 16:13±0.1 minutes for Group B (p<0.05). For the posterior incision, suture passes averaged 48±0.0 in Group A compared to 5±0.0 in Group B (p<0.05). The closure time for Group A was 16:18±0.2 minutes and 16:53±0.1 minutes in Group B (p=0.05).

Conclusion:

Use of the Operative Armour compared to standard technique demonstrated a statistically significant decreased number of suture passes, but no change in total closure time. Given the large reduction in sutures passes, the use of the Operative Armour could lead to a significant reduction in the number of needle sticks in the OR during wound closure. Also, while not measured in this study, the use of Operative Armour could reduce the demand on the scrub tech for assistance with wound closure and could thus decrease OR turnaround time and enhance operating room efficiency.
Outcomes following 3D Printed Total Talus Arthroplasty
Authors: Scott Daniel , Parekh Selene
Published: September 2018

Category:

Hindfoot

Introduction/Purpose:

Many patients with talar avascular necrosis have limited treatment options to manage their symptoms. Historically, surgical options have included pan-talar fusions, tibio-talar-calcaneal fusions, and revascularization procedures. Unfortunately, these treatment options can leave patients with little ankle and hind-foot motion, can increase adjacent joint arthritis, and have significant failure rates. Recently, the use of custom 3D printed total talar replacements has arisen as a treatment option for these patients. Theoretically, this allows for better preservation of hind-foot motion as well as possibly less adjacent joint arthritis.

Methods:

We retrospectively reviewed 15 patients who underwent a 3D printed total talus replacement by a single surgeon over 2 years. Each patient had pre-operative CT scans of both the affected and non-affected talus. Custom 3D printed implants were made in two sizes based on templating performed on the contralateral talus. All total talus replacements were performed through a direct anterior approach. Patient outcomes were reviewed pre and post-operatively including age, sex, comorbidities, etiology of talar pathology, number and type of prior surgeries, as well as VAS scores, range of motion, and number of additional or subsequent procedures.

Results:

The average patient age was 45. 6/15 patients had previously undergone surgery on the ipsilateral hind-foot/ankle. There was a statistically significant decrease in VAS pain scores from 7.0 pre-operatively to 2.5 at final follow up. There was a statistically significant increase in both ankle and sub-talar motion at final follow up when compared to pre-op. Average follow-up was 8.4 months, with a minimum follow up of 3 months. Of the four patients with 1 year or longer follow up (average 13.3 months), VAS scores and ROM were similar to patients with shorter follow up duration. 3 patients had concomitant procedures, most commonly tendo-achillies lengthening. One patient required an additional procedure (incision and drainage) for treatment of wound dehiscence.

Conclusion:

3D printed total talus replacements represent an exciting treatment options for patients with significant talar avascular necrosis. At early follow up, patients showed good improvement in VAS pain scores and actually improved their hindfoot and ankle motion. Certainly, longer term follow-up will be needed to evaluate the longevity of these implants. However, these implants represent an intriguing option for patients that lack an ideal surgical solution and show promise at very early follow up.
Sarcopenia increases the risk for mortality in patients who undergo amputation for diabetic foot
Authors: Seo Sang Gyo , Park EunSoo
Published: September 2018

Category:

Diabetes

Introduction/Purpose:

Although there have been reports that diabetes affects the prevalence of sarcopenia, no studies have examined the relationship between sarcopenia and mortality in patients undergoing leg amputation. The purpose of this study is to determine whether sarcopenia affects the survival and functional outcome of patients undergoing diabetic foot amputation.

Methods:

From among patients who underwent limb amputation for diabetes complications, this study included 167 patients who underwent abdominal CT within 1 year of amputation. We defined sarcopenia using sex-specific cut-off points for the L3 skeletal muscle index. The 5-year survival rate was analyzed. All patients were divided into two groups and compared according to the presence of sarcopenia. We measured the functional activity of the survivors using the Foot and Ankle Ability Measure (FAAM). Differences in FAAM scores were evaluated. The survival rate according to sarcopenia was assessed via the Kaplan-Meier method and log-rank test.

Results:

Among the total of 167 patients, the overall 5-year survival rate was 47.3%. Of the 112 patients with sarcopenia, the 5-year survival rate was 39.3%. Of the 55 patients without sarcopenia, the 5-year survival rate was 63.6%. Kaplan-Meier analysis showed a high mortality of the sarcopenia group in the univariate (p=0.016) and multivariate (p=0.047) analysis. There was no significant difference in FAAM score between two groups (p=0.500).

Conclusion:

Our study is the first to analyze the relationship between diabetic amputation and sarcopenia. Sarcopenia increases the risk of mortality in patients with amputation for diabetic foot. Therefore, the role of sarcopenia and exercise training should be studied in the future to define what role they have in improving functional outcomes in patients who undergo diabetes related amputations.
Staple versus Suture Closure for Ankle Fracture Fixation
Authors: Shah Ashish , Lehtonen Eva , Patel Harshadkumar , Pinto Martim , Phillips Sierra , Naranje Sameer , Pitts Charles , Kalra Rishi , Huntley Samuel
Published: September 2018

Category:

Trauma

Introduction/Purpose:

Ankle fractures are commonly treated fractures by orthopaedic surgeons with unique challenges to skin closure due to the lack of subcutaneous support. Metallic staples are a commonly accepted method of skin closure in other specialties, though the use of staples in orthopaedics, and more specifically in foot and ankle surgery, remains a topic of debate. Proponents of staples report several potential advantages to using staples instead of sutures, including reduced closure time, faster and less painful removal, or improved cosmetic appearance. This study aimed to compare outcomes of suture versus staple closure as well as to evaluate the safety of staple closure after open fixation of acute traumatic ankle fractures.

Methods:

The medical records of 94 patients treated at our institution with open fixation of an acute traumatic ankle fracture by a single surgeon between January 2011 and June 2017 were retrospectively reviewed. Demographics, preoperative characteristics, relevant comorbidities, operative characteristics, and postoperative outcomes were compared between patients who received superficial skin closure using staples versus suture techniques. Statistical analysis was performed using chi-squared test and Fisher’s exact test.

Results:

The staple and suture group patients were demographically similar at baseline. Of the 94 patients included in this study, 10 patients developed local wound related complications postoperatively, including 5 with wound dehiscence, 4 with superficial wound infections, and 1 deep infection . Eight patients required revision surgery due to infection or wound dehiscence. Four patients in the suture group developed superficial wound infections, compared with zero in the staple group. One patient in the staple group developed a deep infection. With the numbers available, no significant differences could be detected in the incidence of postoperative infections, local wound related complications and revision surgeries between two wound closure groups.

Conclusion:

Our data suggests that there is no statistical difference in outcomes between staple and suture closure after open fixation of acute ankle fractures. Because there was no difference in morbidity with possible benefits of reduced closure time, faster removal, and improved cosmetic appearance, we conclude that staple closure may be a safe alternative to sutures for superficial skin closure. This study adds evidence to a growing body of literature and suggests that staples can be used in some instances, clinical decision making, surgeon preference, and technique proficiency should remain the cornerstone of closure in ankle fracture surgery.
Hemi vs. Total joint arthroplasty for hallux rigidus
Authors: Shah Ashish , Stibolt Robert , Patel Harshadkumar , Lehtonen Eva , DeBell Henry , Naranje Sameer , Lee Sung , Huntley Samuel , Moon Andrew , Buddemeyer Katherine
Published: September 2018

Category:

Midfoot/Forefoot

Introduction/Purpose:

Advanced-stage arthritis of the first metatarsophalangeal joint (MTPJ), or “Hallux Rigidus” (HR) is a common forefoot pathology. When surgery is indicated, arthroplasty is an alternative to arthrodesis, which aims to preserve MTPJ dorsiflexion. Since it is unclear whether total-toe or hemi-toe devices are preferred implants in MTPJ arthroplasty, we completed a systematic review of the literature and did a meta analysis to test which type of implants clinically outperform in hallux rigidus.

Methods:

A systematic review of MTPJ arthroplasty was performed using Pubmed, EMBASE, SCOPUS, and Cochrane library for the years 2000 to 2017. Data was extracted from articles containing both preoperative and postoperative endpoints for either hemi or total MTPJ arthroplasty cases. To be eligible for inclusion, studies must have had a mean follow-up window of at least 24 months and standard deviation of outcome. Total eleven studies were included for review, seven studies with hemi replacement and six studies with total arthroplasty. Pooled mean values were calculated, and a forest plot was created comparing pre-and post-operative American Orthopedic Foot and Ankle Score (AOFAS), visual analogue scale (VAS), and range of motion (ROM) results for both hemi-toe and total-toe arthroplasty. Statistical analysis was performed using SPSS.

Results:

Mean postoperative AOFAS scores in patients undergoing hemiarthroplasty improved by 50.7 points (95%CI: 48.5, 52.8), which was higher than the mean postoperative AOFAS improvement of 40.6 points (95%CI: 38.5, 42.8) seen in total-toe patients. Mean postoperative VAS improvement in hemiarthroplasty was 6.05 points (95%CI: 5.92, 6.18), which was comparable to the mean VAS improvement of 6.29 points (95%CI: 6.02, 6.55) seen in total arthroplasty. Mean postoperative MTPJ ROM improved by 43.0 degrees (95%CI: 39.3, 46.6) in hemi-toe patients, which exceeded the mean ROM improvement of 32.5 degrees (95%CI: 29.9, 35.1) found in total-toe cases. A meta-analysis of the data revealed non-significant statistical trends for AOFAS and ROM in favor of hemiarthroplasty.

Conclusion:

Hemi-surface implants in MTPJ arthroplasty may improve postoperative AOFAS and ROM results to a greater extent than total-toe devices. High-quality randomized controlled studies are needed to confirm long-term surgical outcomes in these patients.
Long-term evaluation of Primary Osteochondral Autograft Transfer System (OATS) for large cystic type osteochondral lesion of talus
Authors: Shim Dong Woo , Hwang Yeokgu , Park Kwang Hwan , Lee Jin Woo , Han Seung Hwan
Published: September 2018

Category:

Ankle

Introduction/Purpose:

Osteochondral lesions of talus (OLTs) are often treated primarily by fragment excision, abrasion, drilling, or microfracture. However, OLT accompanying with large cyst has been challenged to yield good outcome nevertheless of many surgical options. Recent study showed significant high failure rate of arthroscopic marrow stimulation treatment larger than 150mm2. The current study is to investigate the outcome of the primary osteochondral autograft transfer system (OATS) for large cystic type OLT (>150mm2).

Methods:

This retrospective analysis included 19 talus (19 patients) with diagnosed large cystic type OLT (>150mm2) who received primary OATS between September 2009 and March 2013. Defect size area was measured on magnetic resonance imaging (MRI) by the ellipse formula from coronal and sagittal length. The patients completed the visual analog scale (VAS) and the American Orthopaedic Foot & Ankle Society (AOFAS) score preoperatively and at follow-up. Plain radiographs were used to show the improvement of radiolucency postoperatively.

Results:

The mean follow up period was 83.9 months (57 – 99) and the average defect size area was 169.4 mm2 (151.3 – 392.6). The Mean VAS score decreased from 6.95 preoperatively to 2.6 postoperatively. Average AOFAS score improved from 66.8 preoperatively to 88.7 postoperatively. Eighty percent of patients rated their result excellent or good. The radiolucent area of the cysts disappeared on the plain radiographs in all cases.

Conclusion:

Long-term clinical results of primary OATS in large cystic type OLT showed good outcomes and patients could significantly benefit from this surgery.
Prevalence of neuropathic pain in the foot and ankle patients
Authors: Sidon Eliezer , McDonald Elizabeth , Daecher Annemarie , Shakked Rachel , Pedowitz David , Daniel Joseph , Winters Brian , Raikin Steven
Published: September 2018

Category:

Other

Introduction/Purpose:

The management of pain in patients with foot and ankle pain can be challenging. Cumulative data suggest that, in addition to nociceptive mechanisms, other neuropathic mechanisms can contribute to pain in a subset of people with osteoarthritis. Neuropathic mechanism include central sensitization or peripheral neuropathic hyper activated pain. Heterogeneous pain mechanisms may explain variable responses to recommended pain therapies. Accurate classification of pain phenotype using clinically feasible tools has potential to improve pain management. The PainDETECT score, a validated patient-report questionnaire was developed to identify neuropathic pain. A recent study found a prevalence of 23% of neuropathic pain following ORIF of Ankle fractures. The purpose of this study is to examine the prevalence of neuropathic pain (NP) in a variety of foot and ankle disorders.

Methods:

This is a cross-sectional study investigating the prevalence of NP in a population of patients undergoing foot and ankle surgery. The patient cohort will include 500 patients. Patients were prospectively reviewed, prior to their surgery, using a patient-self-report questionnaire (painDETECT). Patients’ demographics, diagnosis, comorbidities and functional scores were also prospectively collected. painDETECT score of less than 13 was considered as Nociceptive, score of more than 18 was considered as Neuropathic. Scores of 12 to 18 were considered as Unclear. ANOVA and Student’s t-tests were performed to compare the pain VAS scores, duration of pain prior to surgery, severity of the disease and the prevalence of NP, and among different foot and ankle procedures (bone versus tissue, elective versus trauma) and procedural regions (hindfoot/ankle, midfoot, forefoot).

Results:

A total of 116 patients were included in this preliminary study. 9 patients (7.7%) were diagnosed with neuropathic pain and 24 (20.6%) were Unclear according to their results in the painDETECT. There were 28 patients scheduled for surgery due to recent trauma, none of which had neuropathic pain. One patient with neuropathic pain was scheduled for excision of Morton’s neuroma and 2 patients for removal of foreign body or hardware. There was no significant correlation with age, BMI or smoking status nor with the patients’ functional scores. Patients with NP described their worst and current level of pain significantly higher than those with nociceptive pain. (9.4 Vs 7.4 for worst pain and 6.9 Vs 4.6 for current level in a scale from 0-10, p-value<0.05).

Conclusion:

A considerable number of the patients with foot and ankle problems requiring surgeries also has pain of a neuropathic mechanism. It is more common in chronic pain than in trauma. This should be evaluated pre-op and taken into attention when deciding on a surgical intervention or pain management.
The Influence Of Obesity in Stage IIB Posterior Tibial Tendon Dysfunction Corrective Surgery
Authors: Silva Amila , Rikhraj Inderjeet
Published: September 2018

Category:

Hindfoot

Introduction/Purpose:

In the western population prevalence of posterior tibial tendon dysfunction (PTTD) is said to be 3.3% and it is one of the most commonly undiagnosed foot and ankle pathologies. Stage IIB disease according to Johnson and Strom criteria is managed surgically and there are literature demonstrating good clinical outcomes. Obesity being a global epidemic it affects the patient both biomechanically and biochemically. Aim of the study was to investigate the influence of obesity on functional outcome scores, incidence of postoperative surgical site infection (SSI), and repeat surgery after corrective surgery for stage IIB posterior tibial tendon dysfunction (PTTD).

Methods:

Between January 2007 and December 2013, 102 patients who underwent corrective surgery for stage IIB PTTD at a tertiary hospital were evaluated. We categorized the group with a BMI less than 30 kg/m as control and the group with BMI more than 30 kg/m as obese. The patients were prospectively followed for 2 years. AOFAS mid foot and hind foot scores, mid foot and hind foot VAS scores, SF36 physical and mental function scores were measured pre-operative, post-operative 6 months and post-operative 24 months. SPSS was used for statistical analysis. P value <0.05 was considered as a significant value.

Results:

19.6 percent of our study population was obese, there were 38 males and 64 females. The average age of the population was 44.3years and the average BMI for the population was 28.78kg/m2. Clinical outcomes are as follows SF36 physical function score demonstrated statistical significance (p=0.0001, CI -22.20 to -9.80), AOFAS midfoot scores (p=0.82, CI -9.55 to 7.56), AOFAS hindfoot scores (p=0.23, CI -10.60 to 2.60), Midfoot Visual Analogue Scores (p=0.54, CI 0.31 to 0.76), Hindfoot Visual Analogue Scores (p=0.45, CI 0.21 to 0.68) and SF36 mental health scores (p=0.99, CI -5.76 to 7.74) did not demonstrate any significance (6%) in the control group and 10% in the obese group required repeated surgery for complications.

Conclusion:

Both groups of patients who underwent corrective surgery for stage IIB pttd demonstrated good functional outcomes but there was a significantly higher risk of repeat surgery in the obese group. Obese patients should not be excluded from stage IIB PTTD corrective surgery but patients should be counselled of the higher risk percentage.
Propensity-matched analysis of general versus spinal anaesthesia for patients undergoing ankle fracture surgery
Authors: Sing David , Vora Molly , Tornetta Paul
Published: September 2018

Category:

Ankle

Introduction/Purpose:

The choice of anaesthesia is a modifiable risk factor in optimizing post-operative outcomes in hip and knee surgery, with decreased rates of transfusion, thromboembolic events, and infection with the use of spinal anaesthesia versus general anaesthesia. Regional anaesthesia has been evaluated with respect to its effect on early pain in patients undergoing ORIF of the ankle, but there is no data regarding complication rates. The purpose of this study was to compare operating time, length of stay, and rates of post-operative adverse events within 30-days in patients undergoing open reduction and internal fixation (ORIF) of the ankle using spinal vs. general anaesthesia.

Methods:

Adult patients who underwent ORIF of a closed ankle fracture from 2012 to 2016 were identified from the American College of Surgeons National Surgical Quality Improvement Program database. Patients who were operated on after admission from the ED are not included in the database. Operative time (skin to skin), length of stay, thirty-day adverse events, and unplanned readmissions were compared between patients who received general anaesthesia and those who received spinal anaesthesia. Propensity-adjustment with respect to known risk factors for complications and adjunctive regional block was used to match patients using a 1:4 ratio of spinal to general anaesthesia. Adverse events tracked included wound dehiscence, surgical site infection (superficial and deep), sepsis, venous thrombolic events, cardiac events, prolonged intubation, need for unplanned intubation, return to operating room, pneumonia, urinary tract infection, renal insufficiency, and re-admission within 30 days. Comparisons were performed using a propensity based multivariate analysis.

Results:

Of the 10,795 patients meeting inclusion criteria, 9,862 (91.4%) were treated with only general anaesthesia and 933 (8.6%) were treated with only spinal anaesthesia. Using propensity-scored matching, 822 patients in the spinal cohort were matched to 3,288 patients in the general cohort with similar baseline demographics (61.5% female, mean age 56.4). Procedure performed was similar in both cohorts (47% lateral malleolus ORIF, 34% bimalleolar ORIF, 10% trimalleolar ORIF, 8% medial malleolus ORIF, 1% posterior malleolus ORIF). Spinal anaesthesia was associated with increased length of stay (+0.5 days, 95% confidence interval (CI) 0.20-0.75, p<0.001) and increased mortality (0.6% vs 0.2%, OR: 4.02, 95% CI 1.15-14.1, p=0.03). Rates of overall complications (4.0% vs 4.2%) and readmissions (0.8% vs 0.7%) were similar and available in Table 1.

Conclusion:

General anaesthesia is predominantly used for fixation of ankle fractures. While spinal anaesthesia is associated with lower complication rates in hip and knee surgery, we found no advantage in patients undergoing ORIF of the ankle.
Consumer Prices for Surgical Management of Ankle Arthritis
Authors: Smyth Niall , Dawkins Brody , Goldstein Joshua , Kaplan Jonathan , Aiyer Amiethab
Published: September 2018

Category:

Ankle Arthritis

Introduction/Purpose:

In the United States alone there are over 50,000 new cases of ankle arthritis every year. The financial healthcare burden for surgical management of ankle arthritis likely continues to rise with the volume of total ankle replacements (TAR) increasing 100-fold over the last 20 years. Healthcare consumers however are generally unaware of the costs of the services they use. Understanding the costs associated with operative management of ankle arthritis is an important facet of patient care although access to this information may not be readily available. The purpose of this study was to determine the access to the surgical cost of TARs and ankle arthrodesis and the variability of the cost between the two procedures.

Methods:

50 foot and ankle centers (25 academic, 25 private) that perform TARs and ankle arthrodeses were contacted using a standardized patient script. The described patient was a healthy 63-year-old male who had failed conservative treatment of ankle arthritis. Each institution was contacted up to three times to attempt to obtain a full bundled operative quote for a TAR and an ankle arthrodesis.

Results:

21 centers (42%, 14 academic, 7 private) were able to provide a quote for a TAR and ankle arthrodesis. The mean bundled price for a TAR was $50,332 (SD +/- $25,744) with the mean academic and private center quote being $56,529 and $37,937 respectively. The mean bundled price for an ankle arthrodesis was $41,756 (SD +/- $26,033) with the mean academic and private center quote being $48,116 and $29,037 respectively. There was no statistically significant difference between the bundled price for TAR and ankle arthrodesis.

Conclusion:

There was limited availability of consumer prices for TAR and ankle arthrodesis thus hindering healthcare consumers’ decision making. When comparing different institutions for surgical management of ankle arthritis, there was a wide range of quotes for both TAR and ankle arthrodesis. When comparing the choice of surgical management for ankle arthritis, there was no difference in price between TAR and ankle arthrodesis.
The Use of a Synthetic Cartilage Implant for Hallux Rigidus
Authors: Smyth Niall , Kaplan Jonathan , Aiyer Amiethab
Published: September 2018

Category:

Other

Introduction/Purpose:

Hallux rigidus is one of the most common pathologies afflicting the foot. Various joint salvage techniques have been described with a multitude of different implants. Recently, a synthetic cartilage implant composed of polyvinyl alcohol (PVA) received FDA premarket approval for treatment of arthritis of the great toe and has been used in over 4,000 cases. The purpose of this study was to systematically review the clinical evidence supporting the use of a PVA implant in hallux rigidus.

Methods:

A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). Using the terms “cartiva OR polyvinyl alcohol OR synthetic cartilage OR hemiarthroplasty AND hallux rigidus OR great toe arthritis OR first toe arthritis “ we searched the PubMed/Medline database in December 2017. In addition, the reference list of publications were scanned for further relevant studies.

Results:

4 studies met the inclusion criteria, all of which were derived from a single randomized controlled trial. At short-term follow-up (2 years), patients undergoing placement of a PVA implant had significant improvement in Foot and Ankle Ability Measure (FAAM) sports and activity of daily living, as well as VAS pain scores. The outcomes of the surgery were found to be noninferior compared to arthrodesis. At intermediate follow-up (5 years), the improvement in clinical outcomes persisted and implant survivorship was 96%.

Conclusion:

There are limited studies available detailing the outcomes of a PVA implant for hallux rigidus, however the results that are available demonstrate a high level of evidence. There are no long-term publications assessing the outcomes of a PVA implant for hallux rigidus.
Results and analyses of preoperative isokinetic and balance tests in patients with chronic lateral ankle instability who underwent surgical treatments
Authors: Sung Ki-Sun , Kim Dae-Wook
Published: September 2018

Category:

Sports

Introduction/Purpose:

To (1) describe muscle strength and postural stability in patients with chronic lateral ankle instability, and (2) analyze the correlation between weakness of muscle strength and deficits of postural stability

Methods:

Results of preoperative isokinetic and balance tests in 203 patients whose contralateral ankle was normal were retrospectively reviewed. Isokinetic peak torque values of eversion and inversion at 2 angular velocities (30°/s, 120°/s) were measured in injured and normal ankles. In balance test, the percent differences of 3 actual scores (Overall, Anterior-Posterior, and Medial-Lateral) between injured and normal ankles were calculated. Additional statistical analyses were performed to describe weakness of muscle strength, deficits of postural stability, and their correlation.

Results:

There were significant differences in 4 peak torque values and 4 relative peak torque values (peak torque/body weight) between injured and normal ankles. Eight values were significantly lower in injured ankles. Weakness was severe during inversion and at 30°/s. In balance test, 49 subjects (24.1%) had significant deficits in postural stability; the results in 109 subjects (53.7%) were favorable. There was no strong association between weakness of muscle strength and deficits of postural stability.

Conclusion:

Considering correlation between weakness of muscle strength and deficits of postural stability, strength measurement alone is insufficient in evaluating preoperative functional ability, and other functional test such as postural stability test is required. In addition, the results of this study may provide further evidence for rehabilitation program consisting of proprioceptive training as well as muscle strengthening.
Identifying Risk Factors for Failure of a Modified Broström’s Procedure
Authors: Tadley Madeline , Tan Timothy , Shakked Rachel , Daniel Joseph , Raikin Steven , Pedowitz David
Published: September 2018

Category:

Ankle

Introduction/Purpose:

The modified Broström’s procedure has been widely accepted as the operative treatment of choice for treating lateral ankle instability in patients that have failed nonoperative management. However, the predisposing risk factors for failure of operative treatment, which has important implications for patient selection, is unknown. The purpose of this study is to thus identify independent risk factors for failure of an index Broström’s procedure.

Methods:

A retrospective single institutional study of 123 modified Broström’s procedures, average age 40 years, was performed with a minimum of 2 year follow-up. An electronic query based on Current Procedural Terminology codes was initially performed followed by a manual review of the operative report. Patients with any concurrent osteotomy, arthrodesis, or arthroplasty procedures were excluded. Foot and Ankle Ability Measure (FAAM) and Short Form Survey 12 (SF-12) were obtained both preoperatively and postoperatively. Cormorbidities and relevant demographic information were manually obtained. Treatment success was defined as a postoperative FAAM Sport score increase by greater than 9 points, an established minimal clinical difference established in the literature. A linear regression controlling demographic factors and baseline scores was utilized to predict scores at last follow-up.

Results:

At last follow-up, 31.4% did not demonstrate a self reported clinical improvement in the FAAM Sport scores with 2% (3/123) of the entire cohort requiring reoperation. A higher preoperative physical SF-12 score was associated with a reduction in the postoperative physical SF-12 score (p=0.035) while higher body mass index (p=0.010) was associated lower mental component SF-12 scores at follow-up. Interestingly, higher age is associated with higher 2-year PCS score. Furthermore, the occurrence of a complication was associated with lower ADL (p<0.001), Sport (p=0.002), and total FAAM (p=0.002) scores and higher pain (p=0.017) at 2-years.

Conclusion:

A significant amount of patients did not demonstrate a clinical improvement in functional outcomes although the overall reoperation rate was low. Surgeons should be aware that approximately one third of patients may not have achieved their desired clinical outcome and that BMI and preoperative function is associated with worse outcomes.
Clinical Outcomes Following Minimally Invasive Dorsal Cheilectomy
Authors: Teoh Kar , Tan Weiteen , Hariharan Kartik
Published: September 2018

Category:

Midfoot/Forefoot

Introduction/Purpose:

Hallux rigidus is a degenerative condition of the first metatarsophalangeal (MTP) joint, usually characterised by a dorsal osteophyte. This typically result in impingement pain and limitation of movement of the first MTP joint. Following failure of conservative treatment, a dorsal cheilectomy can be performed for patients in early stages of hallux rigidus. Minimally invasive forefoot surgery is becoming more popular with advances in technology and it is now possible to perform a minimally invasive dorsal cheilectomy (MIDC) of the first metatarsal with a wedge burr. We aim to report our clinical outcomes following MIDC.

Methods:

Eighty-nine patients (98 feet; 44 Right, 36 Left, 9 Bilateral) who had symptomatic hallux rigidis with failed conservative treatment, between 2011 and 2016, were included in this study. The average age was 54 (range: 29 – 71) years old. There were 25 Male and 64 Female in our cohort. They were graded preoperatively by Coughlin and Shurnas Classification (Grade 1, n=30; Grade 2, n=48; Grade 3, n=11). Clinical data were recorded. Pre and postoperative Manchester-Oxford Foot Questionnaire [MOxFQ] scores and visual analog scale (VAS) pain score were collected. The mean follow-up was 50 months (range: 12 - 84).

Results:

Average VAS score improved from 8.0 (range: 6 – 10) preoperatively to 3 (range: 0 – 10) postoperatively. The mean MOxFQ summary index score decreased from 58.6 (range: 30 – 94) preoperatively to 30.5 (range: 0 – 92) postoperatively. All three MOxFQ domains also improved. Swelling took an average of 5.3 (1 – 12) weeks to settle. There were 2 wound infections and 2 delayed wound healing. Two patients had transient nerve paraesthesia while two (2%) patients had permanent numbness in the dorsomedial cutaneous nerve distribution. Twelve patients (12%) had a reoperation, of which 7 had a first MTP joint fusion for ongoing pain (Coughlin Grade 2, n=6; Grade 3, n=1), 4 had repeat cheilectomy for residual impingement, and 1 had an open removal of loose bone.

Conclusion:

Our results suggest that minimally invasive dorsal cheilectomy (MIDC) shows significant improvement in patient reported outcome measure with MOxFQ scores. MIDC seems to be a safe technique with minimal complications. There is an associated learning curve as 5% of our reoperations were due to incomplete cheilectomy. Coughlin grade 1 do well with MIDC but 10% of our grade 2 & 3 went onto a fusion.
Structures at Risk from an Intermetatarsal Screw for Lapidus Bunionectomy
Authors: Van Dyke Bryan , So Eric , Brandao Roberto , Larson David , Hyer Christopher
Published: September 2018

Category:

Midfoot/Forefoot

Introduction/Purpose:

The Lapidus procedure is a common procedure for the treatment of hallux abducto valgus. Traditional fixation consists of two crossing screws in the sagittal plane. Despite arthrodesis of the first tarsometatarsal joint, recurrence of the hallux abducto valgus deformity remains a concern. A transverse screw spanning the base of the first metatarsal to the base of the second metatarsal has been advocated to provide transverse plane stability. However, the neurovascular bundle is located within the proximity of this screw. The literature is sparse with a standard technique to safely provide appropriate fixation. An anatomic cadaver study was undertaken to assess the risk of injury to the neurovascular bundle.

Methods:

Ten unmatched cadaveric limbs that had been disarticulated at the knee were used. Under fluoroscopic guidance, the guide wire to a 4.0-mm screw was driven across the base of the first metatarsal and into the second metatarsal. A 4.0-mm screw was inserted, taking care to obtain osseous purchase into the second metatarsal. A longitudinal incision was made and careful dissection was carried to identify the neurovascular bundle and screw. The neurovascular bundle was inspected for trauma and the proximity of the screws was measured using a digital caliper.

Results:

There were three left-sided and seven right-sided specimens. Five of the specimens were male and five were female. The mean age of the specimens at date of death was 71.4 years. The mean body mass index was 20.5. The mean distance from the 4.0-mm screw to the first metatarsal base 11.24 mm distal to the first tarsometatarsal joint. The deep plantar artery and deep peroneal nerve was free from injury in 10/10 (100%) specimens. However, the screw was measured to be less than 5 mm in three specimens. In these instances, the average distance of the screw distal to the first tarsometatarsal joint was 12.1 mm.

Conclusion:

The addition of the intermetatarsal screw for Lapidus bunionectomy is widely accepted clinical practice. Descriptions of the operative technique for the placement of hardware into the second metatarsal have not included specific recommendations to avoid potential risk to the neurovascular bundle as it courses between the bases of the first and second metatarsals. According to this cadaveric study, the neurovascular bundle was avoided with placement of the intermetatarsal screw, if placed approximately 11.24 mm distal to the first tarsometatarsal joint. Further study is warranted to evaluate the optimal distance distal to the first tarsometatarsal joint.
Conversion of Ankle Fusions to Ankle Replacements
Authors: White Stephen , Cohen Bruce , Jones Carroll , Le Michael , Davis W. Hodges
Published: September 2018

Category:

Ankle Arthritis

Introduction/Purpose:

Ankle arthrodesis remains a prominent treatment choice for ankle arthritis in a majority of patients. Long term studies have shown a compensatory development of ipsilateral adjacent joint arthritis after ankle arthrodesis, and some patients who receive an ankle arthrodesis develop pain in surrounding joints, or even at the fusion site. As total ankle arthroplasty (TAA) design, instrumentation, and techniques have improved, the use of total ankle arthroplasty has become more widespread. Very few studies have been published on conversion of ankle arthrodesis to ankle arthroplasty, but they have shown improved function and patient-related outcome scores. The purpose of this study was to assess the radiographic, clinical, and patient-reported outcomes of patients undergoing ankle arthroplasty after conversion from a CT-confirmed ankle arthrodesis.

Methods:

This was a retrospective cohort study of patients with previous CT-confirmed ankle arthrodesis who underwent conversion to total ankle arthroplasty. Minimum follow up was 1 year. Nonunions of ankle arthrodesis were excluded. AOFAS ankle-hindfoot score, foot function index (FFI), pain, revision surgeries, complications, and patient demographics were assessed. Radiographs prior to TAA, and at latest follow-up were also reviewed.

Results:

10 patients were included in the study with an average age of 54.5 years. No implants had to be revised. 1/10 (10%) patients had to undergo secondary surgery for heterotopic ossification removal. The same patient had to undergo another subsequent surgery for posterior ankle decompression. 2/10 (20%) patients had a mild talar subsidence of the TAA at latest follow-up, with no patients having tibial subsidence. Talar osteolysis was noticed in 2 patients (20%) at latest follow-up, with no patients having tibial osteolysis. Only one patient (10%) was noted to have a mild valgus alignment of TAA with no varus malalignments. All radiographic changes noted were clinically asymptomatic. The average AOFAS total score was 58 (range 23,89). The mean FFI total score was 41.9 (range 0,90).

Conclusion:

Conversion of ankle fusion to TAA is a challenging operation but can be a viable option for patients with ongoing pain after an ankle arthrodesis. We noted low revision rates and few complications at 1 year.
Which is the best treatment for displaced intra-articular calcaneal fractures
Authors: Xuxiang Peng , Pan Xiaohua , Wu XiaoMin
Published: September 2018

Category:

Trauma

Introduction/Purpose:

Displaced Intra-Articular Calcaneus Fractures (DIACFs) represent a source of tremendous disability to the patient, economic burden to the society and a treatment challenge to the average orthopaedic surgeon. Open reduction and internal fixation (ORIF), minimally invasive surgery (MIS), external fixator (EF), external fixator combined with limited internal fixation (EFLIF) and non-surgical treatment (NST) are mostly used for the treatment of DIACFs. However, no single approach is universally applicable to all calcaneus fractures. More over, previous studies was still unclear and have offered conflicting recommendations. The purpose of this study is to comprehensively review the literature and ascertain the relative efficacy and safety of ORIF, MIS, EF, EFLIF and NST for patients with DIACFs using a Bayesian network meta-analysis.

Methods:

We will comprehensively search PubMed, EMBASE, Cochrane Library, Medline, Science Direct, CBM and CNKI from the inception dates to January 01, 2018, to include potentially relevant randomized controlled trials (RCTs) and cohort studies (CSs) that evaluated interventions for treating adults with DIACFs. The quality of included studies was assessed using the Newcastle-Ottawa Scale and the risk of bias according to the Cochrane Handbook. After independent study selection by 2 authors, data were extracted and collected independently. The primary outcome measures were anatomical measures, functional measures, and complications. The data of RCTs and CSs were pooled respectively using the fixed-effect model or random-effect model. Mean differences (MDs) with 95% confidence intervals (CIs) were calculated for continuous data, and relative risks (RRs) with 95% CIs were calculated for dichotomous data. Statistical heterogeneity was assessed with the Q test and I2. Sensitivity analysis was developed to assess the reliability of pooled results.

Results:

Seventeen trials (5 RCTs and 12 CSs) including 2369 patients were considered in the study. EFLIF had significantly the highest AOFAS Ankle Hindfoot Scale (MD, 9.54 [95% CI, 5.97 to 17.42]) and lower total incidence of complications (RR, 1.65 [95% CI, 1.27 to 2.54]) than ORIF, MIS, EF and NST. Moreover, EFLIF resulted in a lower incidence of additional surgery (RR, 3.47 [95% CI, 2.28 to 6.95]) than ORIF and NST. The rank of anatomical recovery was: EFLIF, ORIF, EF, MIS and NST. The rank of functional recovery was: EFLIF, ORIF, MIS, EF and NST. For reduction in total incidence of complications, the rank was: EFLIF, NST, EF, MIS and ORIF.

Conclusion:

EFLIF has the highest probability of improving the functional outcome and reducing the total incidence of complications and additional surgery among the five interventions for treating adults with DIACFs.
Surgical Treatment for Müller-Weiss Disease
Authors: Zhang Ming-Zhu , Yu Guang-rong
Published: September 2018

Category:

Midfoot/Forefoot

Introduction/Purpose:

Müller-Weiss disease is an uncommon osteonecrosis of the tarsal navicular of unknown etiology. Most of them could be treated by non-surgical methods. But some severe deformity and fail to conserved methods. In those cases, surgery may be a reasonable approach.

Methods:

From January 2005 to Septermber 2016, we treated 69 patients suffering from Müller-Weiss disease, using the surgical arthrodesis of the talonavicular joint and naviculocuneiform joint with tricortical autologous iliac crest block fixed by screws and plate.

Results:

All Maceira grades were included. We reviewed the medical records of the patients and took the radiological preoperative and postoperative evaluation. The preoperative and postoperative clinical functions were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot Scale. To treat Müller-Weiss disease, we introduced a surgical arthrodesis of the talonavicular joint and naviculocuneiform joint with tricortical autologous iliac crest bone block fixed by screws and plate. The median follow up was 26 months. All the feet fused solidly. The median time for complete fusion was 13 weeks. The median AOFAS ankle-hindfoot score improved from 45 points preoperatively to 86 points at last follow-up.

Conclusion:

The results of this series demonstrate the arthrodesis of the TNJ and NCJ with tricortical autologous iliac crest graft is a reasonable way for treatment of Müller -Weiss disease. Based on our experience with the patients, we believe that emphasis of the restoration of the length and alignment of the medial column could achieve a good outcome.
View point: gaps in the current guidelines for the prevention of Methicillin-resistant Staphylococcus aureus surgical site infections
Authors: Kavanagh Kevin T. , Abusalem Said , Calderon Lindsay E.
Published: September 2018

The authors advocate the addition of two preventative strategies to the current United State’s guidelines for the prevention of surgical site infections. It is known that Staphylococcus aureus, including Methicillin-resistant Staphylococcus aureus (MRSA), carriers are at a higher risk for the development of infections and they can easily transmit the organism. The carriage rate of Staph. aureus in the general population approximates 33%. The CDC estimates the carriage rate of MRSA in the United States is approximately 2%. The first strategy is preoperative screening of surgical patients for Staph. aureus, including MRSA. This recommendation is based upon the growing literature which shows a benefit in both prevention of infections and guidance in preoperative antibiotic selection. The second is performing MRSA active surveillance screening on healthcare workers. The carriage rate of MRSA in healthcare workers approximates 5% and there are concerns of transmission of this pathogen to patients. MRSA decolonization of healthcare workers has been reported to approach a success rate of 90%. Healthcare workers colonized with dangerous pathogens, including MRSA, should be assigned to non-patient contact work areas. In addition, there needs to be implemented a safety net for both the worker’s economic security and healthcare. Finally, a reporting system for the healthcare worker acquisition and infections with dangerous pathogens needs to be implemented. These recommendations are needed because Staph. aureus including MRSA is endemic in the United States. Policies regarding endemic pathogens which are to be implemented only upon the occurrence of a facility defined “outbreak” have to be questioned, since absence of infections does not mean absence of transmission. Optimizing these policies will require further research but until then we should error on the side of patient safety.