bluuebunny/crossref_metadata_2025 huggingface dataset:
Decreased postoperative gluteus medius muscle cross-sectional area measured by computed tomography scan in patients with intertrochanteric fractures nailing
Authors: Noda Mitsuaki , Saegusa Yasuhiro , Takahashi Masayasu , Takada Yuma , Fujita Masahiro , Shinohara Issei
Published: September 2017

Background:

In patients with femoral intertrochanteric fractures treated by cephalomedullary (CM) nailing, abduction force reportedly decreased by 25–30% during the postoperative follow-up period. The purpose of the current study is to evaluate the cross-sectional area (CSA) and adipose tissue ratio (ATR) of the gluteus medius muscle on the postoperative computed tomography (CT) view, expecting this graphic study will support clinical results.

Materials and methods:

A total of 27 patients with femoral intertrochanteric fractures treated by CM femoral nail implants completed the study. The mean age at osteosynthesis was 83 years (range: 72–94 years). The mean postoperative follow-up period was 23 months. The three CT axial slice views were defined as slices A, B, and C corresponding to proximal, midway, and distal part of gluteus medius, respectively. The CSA and ATR were assessed bilaterally.

Results:

The mean and standard deviation of CSA values (mm2) between the nonoperated/ operated side were as follows: slice A: 2225.8 ± 621.2/1984.5 ± 425.8; slice B: 2145.1 ± 538.3/1854.9 ± 383.9; and slice C: 1711.0 ± 459.0/1434.5 ± 396.9 ( p < 0.01 in slices A, B, and C). The mean and standard deviation of ATR values (%) from the nonoperative/ operative side were as follows: slice A: 2.8 ± 1.7/5.2 ± 3.5; slice B: 2.7 ± 1.9/4.6 ± 3.2; and slice C: 3.6 ± 3.0/4.8 ± 3.2 ( p < 0.01 in slices A and B and p < 0.05 in slice C).

Conclusion:

Our image findings documented that gluteus medius is significantly changed in CSA and ATR. The damage possibly triggers decrease in muscular strength of hip abduction in the postoperative follow-up period. This measurement is objective, and needed no patient’s endurance and cooperation.
Median nerve movement in the carpal tunnel before and after carpal tunnel release using transverse ultrasound
Authors: Nanno Mitsuhiko , Kodera Norie , Tomori Yuji , Hagiwara Yusuke , Takai Shinro
Published: September 2017

Purpose:

We aimed to compare the movement of the median nerve within the carpal tunnel during wrist and finger motions between before and after carpal tunnel release (CTR) using transverse ultrasound in carpal tunnel syndrome (CTS) patients and to evaluate the biomechanical efficacy of CTR for CTS.

Methods:

Twenty-four patients with CTS were examined by transverse ultrasound. The location of the median nerve within the carpal tunnel was examined quantitatively as a coordinate at varied wrist positions with finger extension and flexion, respectively, before and after CTR.

Results:

We found that the median nerve moved statistically significantly more palmarly after CTR than before at all wrist positions during finger motion. The average median nerve displacement toward the palmar side at the palmar flexion position in finger flexion was the greatest among all positions. Additionally, the displacement amounts of the median nerve during finger motion at all wrist positions were statistically significantly smaller after CTR than before.

Conclusions:

The current study demonstrated the movement patterns of the median nerve in the carpal tunnel during wrist and finger motions compared before and after CTR using transverse ultrasound in CTS patients. The findings suggested that as the median nerve shifted greatly palmarly away from the tendons after CTR, the nerve avoids compression or shearing stress from the tendons. This ultrasound information could offer further understanding of the pathomechanics of CTS and provide a more accurate diagnosis of CTS and better treatment by CTR.
Identification of the location of the A1 pulley combining palpation technique with palm landmarks and percutaneous release of A1 pulley with a 19-gauge needle: A cadaveric study
Authors: Grinčuk Aleksandr , Baužys Karolis , Porvaneckas Narūnas , Uvarovas Valentinas , Rauba Gediminas , Ryliškis Sigitas
Published: September 2017

The aims of this study were to identify the location of the A1 pulley combining palpation technique with superficial palm landmarks and to determine the efficacy and safety of A1 pulley percutaneous release with a 19-gauge needle. Fourteen fresh frozen cadaveric specimens were used: 56 fingers and 14 thumbs. The location of the A1 pulley was based on anatomical landmarks and was identified in all digits. Complete release of the A1 pulley occurred in 60 of the 70 digits (85.7%). The length of the A1 pulley in thumbs was 5.7 mm and in other fingers 4.5 mm. There were no signs of neurovascular bundle injuries. The mean distance between needle pathway and neurovascular bundle was 4.3 mm in the thumbs and 6.5 mm in the other fingers. There were no total flexor tendon injuries. The location of the A1 pulley can be predicted with success. Percutaneous release of the A1 pulley with a 19-gauge needle shows acceptable results in both safety and efficacy.
Institutional Excellence: A Model-based Study on Faculty Perception
Authors: Shukla O. P. , Garg Suresh
Published: September 2017

This research study has been undertaken to understand and study the perception of faculty members regarding various input parameters of an institution, which generally students look at from outside at the time of admission such as faculty, infrastructure, reputation and placements. In addition to this, the study has been conceptualised to identify the underlying factors as per faculty perceptions which have an impact on the growth of the institution and well-being of the students. This study was able to gauge different factors which had an impact on the proper functioning of institutions. Exploratory factor analysis (EFA) helped in the identification of underlying factors which were further tested for validity via the confirmatory factor analysis (CFA). Structural equation modelling was further employed to establish structural relationship between underlying factors identified and to build a model.
The Use of Patient-Specific 3D Printed Titanium Implants for Complex Foot and Ankle Limb Salvage, Deformity Correction, and Arthrodesis Procedures
Authors: Adams Samuel , Dekker Travis , Steele John , Hamid Kamran
Published: September 2017

Category:

Ankle,Ankle Arthritis,Basic Sciences/Biologics,Trauma

Introduction/Purpose:

Large lower extremity bony defects, complex foot and ankle deformities, and high-risk arthrodesis situations can be difficult to treat. These challenging pathologies, often require a critical-sizes and/or shaped structural bone void filler which may not be available with allograft bone. The advancement of 3D printing technology has allowed for the use of custom designed implants for foot and ankle surgery. This study reports on the radiographic and functional outcomes of a case series of patients treated with patient-specific 3D printed titanium implants.

Methods:

Seven consecutive patients who were treated with custom designed 3D printed implant cages for severe bone loss, deformity correction, and arthrodesis procedures were included in this study. A minimum of 1-year follow-up was required. No patients were lost to follow-up. Patients completed preoperative and most recent follow-up VAS for pain, FAAM, and SF-36 outcomes questionnaires. All patients had post-operative radiographs and CT scans to assess bony incorporation.

Results:

The mean age of these patients was 54.6 (35-73 years of age). The mean follow-up of these seven patients was 17.1 months (range 12 to 31). Radiographic fusion with cage ingrowth and integration occurred in all seven patients verified by CT scan. There was statistically significant improvement in all functional outcome score measures (VAS for pain, FAAM, and SF-36). All patients returned were satisfied with surgery. There were no failures. Case examples are demonstrated in Figure 1.

Conclusion:

This cohort of patients demonstrated the successful use of custom 3D printed implants to treat complex large bony defects, deformities and arthrodesis procedures of the lower extremity. These implants offer the surgeon a patient specific approach to treat both pain and deformity that is not necessarily available with allograft bone.
Is Revision Anatomic Ankle Ligament Repair Augmented with Suture-Tape a Valuable Alternative for Patients with Failed Broström Procedure?
Authors: Choi Seung-Myung , Cho Byung-Ki , Lee Gi-Soo
Published: September 2017

Category:

Ankle, Sports

Introduction/Purpose:

Recurrent instability after previous anatomic ankle ligament repair has been known to be a poor prognostic factor for revision modified Broström procedure, and ligament reconstruction procedures using an allograft or autograft tendon have commonly been recommended. This prospective study was performed to evaluate the intermediate-term outcomes after revision anatomic ankle ligament repair augmented with suture-tape for failed modified Broström procedures.

Methods:

Thirty patients with failed modified Broström procedures consecutively underwent revision procedures for recurrent ankle instability. Of these patients, 27 patients who could be followed for more than 2 years were analysed in the current study. The clinical evaluation consisted of the Foot and Ankle Outcome Score(FAOS), Foot and Ankle Ability Measure(FAAM) score. Talar tilt angle and anterior talar translation were measured to evaluate radiologically the changes of mechanical ankle stability.

Results:

FAOS and FAAM scores significantly improved from preoperative averages of 53.6 and 45.6 points to 87.5 and 85.1 points at final follow-up, respectively (p < 0.001). Talar tilt angle and anterior talar translation had significantly improved from preoperative averages of 15.1° and 12.4 mm to 2.8° and 4.1 mm at final follow-up, respectively (p < 0.001). Preoperative side to side comparison in stress radiographs demonstrated statistically significant difference (p < 0.001), but there was not significant side to side difference in these radiographic measures at final follow-up (p > 0.05). Postoperative complications included 2 cases of local wound problems, 2 cases of superficial peroneal nerve injury, and 1 case of recurrent instability.

Conclusion:

The revision modified Broström procedure augmented with suture-tape appears to be an effective treatment method for recurrent ankle instability in patients with prior failed modified Broström procedure. This combined procedure can provide reliable stability and satisfactory clinical outcomes through supplementation of the anatomic repair of attenuated ligaments using suture-tape.
Outcomes of Flexor Digitorum Longus (FDL) Tendon Transfer for the Treatment of Chronic Achilles Tendinopathy
Authors: de Cesar Netto Cesar , Chinanuvathana Apisan , Da Fonseca Lucas Furtado , Baquero Andres O’Daly , Tan Eric , Atwater Lara , Schon Lew
Published: September 2017

Category:

Hindfoot, Sports

Introduction/Purpose:

Flexor hallucis longus (FHL) tendon transfer is a common surgical technique used for augmentation during the surgical treatment of chronic Achilles tendinopathy and reconstruction. Flexor digitorum longus (FDL) tendon transfer represents a viable surgical alternative for patients with failed FHL transfers or athletes where compromise of the hallux push off strength could negatively impact their level of activity. There is no reported clinical outcome data about this technique in the current literature. Our study describes the clinical and functional results after FDL tendon transfer for the treatment of patients with chronic Achilles tendinopathy.

Methods:

We retrospectively assessed prospectively collected data on patients that underwent FDL tendon transfer in the treatment of chronic Achilles tendinopathy (March 2012 - March 2015). Charts were reviewed for clinical data, associated treatments and complications. Preoperative assessment included the Visual Analogue Score (VAS), SF-36 health status survey and the lower extremity functional scale (LEFS). At final follow up we evaluated pain level, range of motion of the ankle and the toes, ability to perform single leg raise and toe walking, calf atrophy and complications. Postoperative outcomes were assessed by Visual Analogue Score (VAS), SF-36 health survey, Lower Extremity Functional Scale (LEFS), Foot Function Index (FFI), VISA-A score and the Foot and Ankle Ability Measure (FAAM). Fifteen patients (seventeen feet), 6 males and 9 females, mean age of 53.6 years (27- 76 years) and an average body mass index of 31.4 kg/m2 (20.5 to 45.4 kg/m2) were included in the study.

Results:

Mean follow-up was 27.5 months (15-49). Four patients (6 feet) had prior surgeries, including two patients with failed FHL transfer. We found significant clinical improvement when comparing pre-operative and postoperative VAS scores (6.0±3.3 versus 1±1.36; p<0.001), SF-36 physical component summary (28.2±10.7 versus 45.0±11.1; p<0.002) and LEFS (36.4±22 versus 57.9±20.5; p<0.011). At final follow up, 6/7 patients (86%) returned to prior levels of recreational sport activities. No differences were found on single leg raise test when compared to uninvolved side. One patient reported weakness for plantar flexion of the toes, without gait complaints. Mean VISA-A was 52.6 points (15-85), Foot Function Index (FFI) 21.2% (0-65%) and FAAM 86.2% (55.3-100%) for the FAAM. Three patients had superficial infection and two patients had deep infection, requiring surgical debridement.

Conclusion:

FDL tendon transfer represents a safe surgical alternative as a method of augmentation during the treatment of chronic Achilles tendinopathy. Our study showed comparable clinical and functional outcomes to FHL tendon transfer and minimal complications or donor site morbidity.
Outcomes of Lisfranc Injuries in an Active Duty Military Population
Authors: Hawkinson Michael , Osborn Patrick
Published: September 2017

Category:

Midfoot/Forefoot, Sports, Trauma

Introduction/Purpose:

Traumatic injuries to the tarsometatarsal or Lisfranc joints can be complex problems associated with long-term pain, disability, and deformity. Most current literature advises early open reduction and internal fixation (ORIF) for acute Lisfranc injuries and reserves arthrodesis for chronic injuries, isolated ligamentous injuries, or salvage procedures. There is also a reported association between delayed diagnosis or missed injuries and poor outcomes. The purpose of this study was to evaluate the association between time from injury to treatment and method of fixation with outcome.

Methods:

A retrospective review of 171 non-battle related closed tarsometatarsal dislocations and fracture dislocations was conducted of patients identified using the Department of Defense Trauma Registry and Military Health System Mart from 2009- 2014 searching by CPT codes. Demographic information, injury characteristics, treatment course, and physical evaluation board results were examined. Return to duty was defined as a patient returning to full duty and passing their service specific physical fitness test. We excluded polytrauma patients, battle injuries, deep infections requiring surgical debridement, those with pre- existing duty limiting conditions, those who separated from the military for unrelated reasons prior to completing their rehabilitation and those with incomplete data.

Results:

Overall of 107 patients 69% returned to full active duty, 4% returned to limited duty with permanent duty restrictions and 27% underwent a medical evaluation board and were ultimately discharged from service. The ORIF group consisted of 80 patients; the average time from injury to fixation was 2.5 weeks and 63% returned to full duty, 6% returned on permanent profile. Of the arthrodesis group 20 underwent primary arthrodesis with an average time from injury of 15.4 weeks and a return to duty rate of 80%. Seventy-one percent of patients who underwent arthrodesis as a salvage procedure for failed ORIF or post-traumatic osteoarthritis (PTOA) underwent a medical evaluation board and were discharged from service.

Conclusion:

This represents one of the largest cohorts in the literature and redemonstrates that tarsometatarsal dislocations and fracture-dislocations are serious injuries that can lead to permanent disability. The data also demonstrates very low return to duty rates in those who underwent salvage arthrodesis reinforcing the importance of initial anatomic reduction and the poor outcomes of PTOA. Most notably it demonstrates higher return to duty rates among patients who underwent primary arthrodesis despite the inclusion of more missed/chronic injuries when compared to ORIF. This suggests that primary arthrodesis may be a viable option in a young and active population despite later treatment.
3D CT Analysis of Distal Tibiofibular Syndesmosis Symmetry
Authors: Hoopes Daniel , Sangeorzan Bruce , Ledoux William , Pihl Connor , Edinger Kylie , Kindig Matthew
Published: September 2017

Category:

Ankle, Trauma

Introduction/Purpose:

As medical imaging of the syndesmosis prior to ankle injury is usually not available, researchers have diagnosed and surgically reduced syndesmotic disruptions based on presumed symmetry with the healthy contralateral limb. The purposes of this study are to quantify the degree of symmetry present in the DTFS using 3D CT modeling, and to compare the accuracy of common clinical two-dimensional (2D) measurements to 3D CT measurements for assessing syndesmotic symmetry and measuring diastasis.

Methods:

Bilateral lower limb CT (n=65) were assessed, were segmented, and reconstructed into 3D surface models, and an anatomically-defined coordinate system was applied to orient the 3D models uniformly. Symmetry was assessed three- dimensionally to overlap the left and right. The relative differences between the two fibulae were quantified in six degrees of freedom. For comparative purposes, four 2D measures were also measured. These measures included anteroposterior (AP), mediolateral (ML), and rotational displacement of the fibula relative to the tibia, measured using axial CT, and longitudinal displacement, measured using coronal radiographs. The four measures were automatically calculated using custom software to reduce the influence of inter- and intra-rater variability. The absolute difference was calculated for each 3D and 2D measure. The differences measured represent the amount of translation or rotation needed to match the position of the left fibula to the position of the right fibula after reflection and optimal tibial alignment.

Results:

The mean difference in AP displacement was approximately double the mean difference in ML displacement for the 2D measurements (1.65 mm vs 0.71 mm), while AP and ML displacement differences for the 3D measurements were comparable (0.57 mm and 0.44 mm). As a general trend, the 2D measurements exhibited larger values of absolute differences than the 3D measurements. The average difference in fibular rotation detected was larger for the 2D measurements (6.1°) than the 3D measurements (0.59°). . The 2D AP displacement differences varied between 1.41 -1.95 mm (95% CI), which is beyond the suggested 1 mm tolerance level. The 3D analog of this measurement varied between 0.47-0.70 mm (95% CI), which is within the suggested threshold.

Conclusion:

Some clinical reports suggest that 1 mm misalignment can cause pain and require surgical revision, but detecting asymmetry below 1 mm is limited by the quality of clinical 2D imaging. Our findings suggest that the current standard practice of using 2D measures to assess the DTFS may exaggerate the amount of asymmetry present, which may lead to misdiagnoses and subsequent surgical revisions. Natural symmetry exists in uninjured syndesmoses. More accurate comparisons of syndesmotic alignment may be needed to determine the accuracy of DTFS diastasis.
The Radiologic Change of Distal Tibiofibular Joint Following the Removal of the Transfixing Screw After Syndesmotic Injury
Authors: Jeong Bi O , Baek Jong Hun , Song Wookjae
Published: September 2017

Category:

Ankle, Trauma

Introduction/Purpose:

Transfixing screw fixation is required after anatomic reduction of syndesmosis disruption. An accurate anatomic reduction is related to good functional outcome. However, there is a dispute over whether the transfixing screw should be removed, and little is known about the change of syndesmosis integrity after screw removal. This study aimed to evaluate the effect of transfixing screw removal on syndesmosis integrity with computed tomography (CT) scans.

Methods:

The study was done prospectively on 28 cases (28 patients) who had transfixing screw fixation for syndesmosis injury from September 2010 to August 2016. Mean age was 31.9 years (range, 17 to 55 years). There were 20 male patients and 8 female patients. Transfixing screws were removed after 3 months, and CT scans were done just before and 3 months after transfixing screw removal. Anterior and posterior measurement ratio (A/P ratio) of the syndesmosis was measured on axial CT images for radiological analysis of changes in syndesmosis integrity between before and after screw removal.

Results:

Malreduction was observed in 7 cases (25%) before transfixing screw removal. All 7 cases were anterior malreductions. Syndesmosis was spontaneously reduced after screw removal in 5 out of the 7 malreduction cases (71.4%). The A/P ratio in the 7 cases decreased from average 1.37 (range, 1.25 to 1.61) before screw removal to average 1.12 (range, 0.96 to 1.25) after screw removal. The decrease was statistically significant (p = 0.016). Syndesmosis malreduction rate decreased from 25% before screw removal to 7.1% after screw removal. All patients with adequate reduction of their syndesmosis continued to have a reduced syndesmosis after transfixing screw removal. However, this difference in malreduction rate was statistically insignificant (p=0.063).

Conclusion:

Although the malreduction rate is relatively high after transfixing screw fixation in disrupted syndesmosis, the malreduced syndesmosis was spontaneously reduced in 71% of cases after screw removal. Therefore, it is beneficial to remove the transfixing screw a certain period of time after transfixing screw fixation to achieve anatomic reduction of the syndesmosis.
Second-Look Arthroscopic Findings and Clinical Outcomes After Management of Intra-Articular Lesions in Acute Ankle Fractures with Arthroscopy
Authors: Kim Jeon-Gyo , Gwak Heuichul , Roh Sangmyung
Published: September 2017

Category:

Ankle, Arthroscopy, Trauma

Introduction/Purpose:

Anatomically successful surgical reduction of ankle fractures does not always result in a clinically favorable outcome. The purpose of the present study was to compare initial and second look arthroscopic finding of acute ankle fracture and to evaluate clinical outcomes.

Methods:

A total of 39 patients (40 ankles, 20 male, 20 female) who underwent surgery for ankle fracture between March 2009 and August 2016 were retrospectively reviewed. All patients gave consent to the exploratory arthroscopic surgery for the removal of internal fixation devices placed in the initial surgery. Intra-articular lesions (osteochondral lesion, loose body, injury of ligaments and fibrosis) were evaluated via ankle arthroscopy. Arthroscopic finding of osteochondral lesion were classified using the Ferkel and Cheng staging system, and cartilage repair was assessed using the international Cartilage Repar System (ICRS). Clinicial outcomes were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale and Visual Analogue Scale (VAS)

Results:

Chondral lesions were found in 26 ankles (65%) with initial arthroscopic finding of acute ankle fracture. Newly discovered chondral lesions in second-look arthroscopy was 15 cases. Accoding to the Ferkel and Cheng staging at second-look arthroscopy, 4 of 23 ankles with chondral lesions of talus was getting worse (more than stage D). In terms of ICRS overall repair grades, 4 ankle (15%) were abnormal (grade III). Diffuse synovitis and arthrofibrosis were found in 12 and 7 ankles respectively in second-look arthroscopy. Correlation were found between AOFAS scores, VAS and intra-articular lesions with second-look arthroscopy.

Conclusion:

Second-look arthroscopic examination combined with treatment of intra-articular lesion arising from ankle fracture surgery may consider to improve clinical outcomes.
The Fate of Bone Graft for Periprosthetic Osteolysis in Total Ankle Arthroplasty
Authors: Park Yoo Jung , Shim Dong-Woo , Hwang Yeokgu , Lee Jin Woo
Published: September 2017

Category:

Ankle Arthritis

Introduction/Purpose:

Periprosthetic osteolysis in total ankle arthroplasty (TAA) is a substantial problem. It may cause implant failure and has potential to affect long-term implant survival. To prevent major revisional arthroplasty, it is important to make an early diagnosis of osteolysis and decide an appropriate timing of surgical intervention such as bone graft. We report our experience of bone graft for osteolysis after TAA associated with clinical and radiologic outcome.

Methods:

Between May 2004 and Oct. 2013, 238 primary TAA were performed on 219 patients. We excluded 37 ankles with follow-up less than 24 months; thus, 201 ankles in 185 patients with mean follow-up of 61.9 (range, 24-130) months were included in the study. Nineteen patients were treated with a total of 21 bone graft procedures for periprosthetic osteolysis after TAA. Of these patients, 12 (57.1%) were males with mean follow-up length after bone graft 35.0 months. Location of osteolysis, bone grafting method and clinical outcome parameters using visual analog scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) score were recorded.

Results:

Radiographs revealed total of 62 osteolysis lesions in 19 patients; 35 (56.5%) distal tibial lesions, 23 (37.0%) talar lesions. Autogenous iliac bone graft was used in 18 procedures (85.7%). The mean scores (and standard deviation) improved for the VAS from 4.8 ± 1.23 points before bone graft to 3.0 ± 0.94 points at the last follow-up (p<0.05); and for the AOFAS score from 76.8 ± 5.9 before bone graft to 84.3 ± 4.5 at the last follow-up (p<0.05). After 21 bone graft procedures, 6 demonstrated detection of newly developed osteolysis. One patient needed a repeat bone graft procedure with cementation after the primary bone grafting due to large cyst on distal tibia. There was no implant failure or major revisions after the bone graft.

Conclusion:

Bone graft for periprosthetic osteolysis may improve patient’s clinical outcome and give support to the structures surrounding the implant. Bone grafting in optimal timing may also improve implant survivorship. However, further study is needed for the etiology of newly developed painless osteolysis even after the bone graft.
Chronic Deltoid Ligament Insufficiency Repair with Internal Brace™ Augmentation
Authors: Pellegrini Manuel , Carcuro Giovanni , Cuchacovic Natalio , Somarriva Marcelo , Heldt Mario Escudero , Torres Nicolas , Birman Eddie , Muñoz Gerardo
Published: September 2017

Category:

Ankle, Arthroscopy, Sports

Introduction/Purpose:

Patients with chronic deltoid ligament insufficiency (CDLI) present a challenging situation in foot and ankle surgery. Although numerous surgical procedures have been described, optimal treatment is still a matter of debate. While the treatment armamentarium ranges from simple ligament repair to complex deltoid reconstructions with or without realignment osteotomies, direct repair augmented with an Internal Brace™ (Arthrex, Inc., Naples FL, USA) device appears to be an attractive intermediate option. We investigated functional outcomes and complications in patients with CDLI operated on using Internal Brace™ augmentation.

Methods:

After IRB approval, a prospective study was conducted. Patients were included if they were older than 18 years, presented medial ankle pain and/or giving way, exhibited asymmetric flexible hindfoot valgus, failed conservative treatment, and had a positive MRI evaluated by an independent radiologist. Patients with less than six months of follow-up, stage IV flatfoot deformity, neuropathy and/or inflammatory arthritis were excluded from the study. CDLI diagnosis was confirmed intraoperatively with the arthroscopic ankle drive-through sign. Patients were evaluated preoperatively and postoperatively using foot and ankle ability measure (FAAM) score, 36-item short form survey (SF-36), and grade of satisfaction. Paired t-tests were used to assess the pre- and postoperative FAAM and SF-36 scores.

Results:

Eleven patients met inclusion criteria. Nine patients were male and two female, with a mean age of 32 (18-61). Six ankles were right and five left. 88% presented with medial ankle pain, 67% medial drawer, 88% asymmetric hindfoot valgus, and 44% multidirectional ankle instability. No patient was lost to follow-up, with a mean follow-up time of 13.5 months (6-21). Preoperative FAAM and SF-36 scores improved from 58.7 to 75.3 and from 60.2 to 84.4 postoperatively, respectively (p<0.05). Two implant failures were observed, with no apparent compromise of construct stability. No patient was re-operated.

Conclusion:

Our results suggest that deltoid ligament repair with Internal Brace™ augmentation in patients with CDLI is a reliable option with good functional outcomes and high satisfaction grade in short term follow-up.
Deformity and Clinical Outcomes Following Surgical Correction of Charcot Foot
Authors: Pinzur Michael , Schiff Adam
Published: September 2017

Category:

Diabetes

Introduction/Purpose:

There is growing acceptance that the historic accommodative treatment of the acquired deformity associated with Charcot Foot arthropathy leads to very poor patient reported outcomes. Surgical correction of the acquired deformity is now advised with the goals of improving ambulation and quality of life.

Methods:

Over a twelve-year period, 214 consecutive patients (9 bilateral) underwent surgi-cal reconstruction of the acquired deformity associated with symptomatic midtarsal dia-betes- associated Charcot Foot arthropathy. The patterns of midtarsal deformity were ar-bitrarily stratified into three clinical groups based on observed weight bearing pattern, radiographic relationship of the forefoot to the hindfoot and integrity of the talo-calcaneal joint. All patients were followed for a minimum of one year. All had weight bearing radiographs before surgery and at a minimum of one year following surgery. A VALGUS deformity pattern was present in 138, VARUS in 48 and DISLOCATION of the talo-calcaneal joint in 37. Surgery included tendon-Achilles lengthening and an attempt at bony correction of the non-plantigrade clinical deformity. Immobilization in all cases was accomplished with a three level static circular external fixator. Clinical outcomes were based on suc-cessfu1 resolution of infection and the ability to resume independent walking with com-mercially-available therapeutic footwear.

Results:

Seven patients died within a year of surgery. Overall, 173 of 216 feet (80.1%) achieved a favorable clinical outcome rating. The VALGUS deformity pattern was the most common, with 120 of 138 patients (89.6%) achieving a favorable clinical outcome rating. There were two transtibial and one transmetatarsal amputations in this group. Twenty-seven of the 48 patients (58.7%) with a VARUS deformity pattern achieved a favorable clinical outcome rating, with seven undergoing transtibial, one Syme’s and one transmetatarsal amputation. There were thirty- seven patients with a valgus deformity pattern characterized by loss of integrity, i.e. DISLOCATION, of the talo-calcaneal joint. Correction of deformity and a favorable clinical outcome rating was achieved in twenty-six (72.2%), with one knee disarticulation and two transtibial amputations.

Conclusion:

Overall, 176 of 223 (77.6%) patients, many with severe structural deformity and osteomyelitis, achieved a favorable clinical outcome. Patients with a VARUS deformity pattern, or loss of integrity of the talocalcaneal joint, were less likely to achieve a favora-ble clinical outcome rating. This retrospective case series suggests a reasonably good probability of improving clinical outcomes in this complex patient population. This de-formity stratification should be helpful going forward when counseling patients with non-plantigrade diabetes- associated Charcot Foot deformity on the risk-benefit ratio associat-ed with surgical correction of their acquired deformity.
Matrix-Associated Stem Cell Transplantation (MAST) in Chondral Defects of the Ankle is Safe and Effective - 5-Year-Followup
Authors: Richter Martinus , Meissner Stefan , Zech Stefan
Published: September 2017

Category:

Ankle, Arthroscopy, Sports

Introduction/Purpose:

The aim of the study was to assess the 5-year-follow-up of matrix-associated stem cell transplantation (MAST) in chondral defects of the ankle.

Methods:

In a prospective consecutive non-controlled clinical follow-up study, all patients with chondral defect that were treated with MAST from April1 2009 to September 30, 2011 were analyzed. Size and location of the chondral defects and the Visual- Analogue-Scale Foot and Ankle (VAS FA) before treatment and at follow-up were analysed. Stem cell-rich blood was harvested during the procedure from the ipsilateral pelvic bone marrow with a Jamshidi needle (10 x 3 mm, Cardinal, Dublin, OH, USA) and a special syringe (Arthrex-ACP, Arthrex, Naples, FL, USA) through a stab incision. The syringe was centrifuged (10 minutes, 1,500 rotations per minute). The supernatant was used to impregnate a collagen I/III matrix (Chondro-Gide, Geistlich, Wollhusen, Switzerland) that was cut to the size of the cartilage defect roughly before and definitely after. The matrix with stem cells was fixed into the chondral defect with fibrin glue (Tissucoll, Deerfield, IL, USA).

Results:

Sixty-six patients with 69 chondral defects were included in the study. The age of the patients was 35 years on average (range, 12-64 years). VAS FA before surgery was 48.9 on average (range, 16.5-75.9). The defects were located as follows, medial talar shoulder, n=28; lateral talar shoulder, n=28 (medial and lateral talar shoulder, n=3), tibia, n=3. The defect size was 1.4 cm2 on average (range, .6 - 6 cm2). 60 patients (91%) completed 5-year-follow-up. No patient was converted to fusion or total ankle replacement. The VAS FA improved to an average of 78.2 (range, 60.8-100; p=.01).

Conclusion:

MAST led to improved and high validated outcome scores at 5-year-followup. No method related complications were registered. Even though a control group is missing, we conclude that MAST is an effective method mid-term for the treatment of chondral defects of the ankle.
Primary Results of Bone Biopsies in Outpatients with Neuropathic Ulcers
Authors: Vris Alexandros , Massa Edward , Ahluwalia Raju , Kavarthapu Venu
Published: September 2017

Category:

Diabetes

Introduction/Purpose:

Patients with Charcot foot disease often develop ulcers that probe to bone due to progressive deformity and loss of protective sensation. Infection of the ulcers and the underlying bone is common. In order to diagnose and treat osteomyelitis, especially in cases where reconstruction is planned, the pathogen must be isolated. The need for bone debridement and the duration of antibiotic treatment depends on the presence of bone infection. Percutaneous bone biopsies through intact skin is the gold standard for acquisition of samples for cultures. The presence of neuropathy negates the need for anaesthesia and renders biopsies possible in the outpatient setting. In our study we compare the results of bone biopsies with wound swabs and document the safety of the technique in clinic.

Methods:

Thirty five patients were included in the study. Inclusion criteria were the presence of neuropathy and foot ulcers with exposed bone (Grade 3 University of Texas wound classification). Samples were obtained by three different doctors with aseptic technique through intact skin and sent for cultures. The area of the bone where the sample was taken from was defined by the location of the ulcer, the available imaging and anatomical landmarks. Complications such as bleeding and entry point infection and delayed healing were documented. Superficial ulcer swabs were also obtained for comparison.

Results:

In 37 patients 2 procedures were abandoned due to pain; otherwise no complications during or after the biopsy were recorded and the procedure duration was 4 minutes at most. There was bacterial growth in 40% of bone biopsy samples, compared to 65.7% of superficial swabs. Cultures were polymicrobial in 35.7% of positive biopsies and 82.6% of positive ulcer swabs. Concordance between bone biopsy and swab results was seen in 16/35 (45.7%) of samples. In 7 patients both tests were negative and in 9 both positive. 7/9 of samples that were positive with both methods grew the same organism.

Conclusion:

Our study showed that there is poor concordance of the results of the two tests. Wound swabs have high rates of polymicrobial cultures; in comparision bone biopsies are more reliable in confirming a specific microbial organism and dictating the need for and type of antibiotic. Targeted antibiotics can thus be safely used, potentially reducing the complications and the cost of broad-spectrum antibiotic treatment. The technique of needle bone biopsy is easy, safe and reproducible, and pain is not a limiting factor for in outpatients with neuropathy.
Ligament Balancing During TAR in Varus Deformity by Open Wedge Osteotomy of the Medial Malleolus
Authors: Wagener Joe , Schweizer Christine , Zwicky Lukas , Hintermann Beat
Published: September 2017

Category:

Ankle Arthritis

Introduction/Purpose:

After reducing the tilted talus during total ankle replacement (TAR) in severe varus deformities, the surgeon is faced to a contract medial joint and an abducted medial malleolus leaving a wide gutter. A sliding osteotomy will release the deltoid ligament but the “horizontal” position of the medial malleolus remains and bony containment of the ankle joint is not restored. We propose an open wedge osteotomy, which will both lengthen and adduct the medial malleolus and restore ligament balancing. Fixation is done by either screw or plate fixation. We present our primary results with this new technique.

Methods:

From 2008-2015 Total Ankle Replacement combined with open wedge medial malleolar osteotomy was done in 50 ankles (48 patients). Inclusion criteria: Takakura stages 3 and 4 ankle arthritis. Minimum follow-up was defined as one year.

Results:

Neutral alignment was achieved in all ankles at last follow-up. AOFAS score increased from 36 preoperative to 82 at last follow-up. In 15 Ankles an additional bony procedure was done during the TAR surgery (Calcaneus Osteotomy: 5, Dorsiflexion Osteotomy of first ray: 6, Fibula Osteotomy: 4, peritalar fusion: 4) Complications included one non-union of the medial malleolus, which resolved after revision. One deep infection that was treated in a staged procedure with reimplantation of a TAR and no recurrence of infection. Two luxations of the polyethylene due to insufficient lateral ligaments and syndesmotic dehiscence, both were stable at final follow-up after revision (ligament reconstruction and tight-rope Fixation).

Conclusion:

Open wedge osteotomy of the medial malleolus restores the bony containment of the ankle joint and decreases the tension of the deltoid ligament. It is a valuable tool for ligament balancing during TAR.
Peroneal Tendon Tears
Authors: Wagner Emilio , Wagner Pablo , de Solminihac Diego Zanolli , Ortiz Cristian , Díaz Andres Keller , Radkievich Ruben , Palma Felipe , Guzman-Venegas Rodrigo
Published: September 2017

Category:

Ankle, Basic Sciences/Biologics, Sports

Introduction/Purpose:

Peroneus brevis tendon tears are frequently diagnosed when ankle instability is present. No clear guideline exists as to when to repair or resect peroneal tendon tears, as most of the available literature uses Meyer’s work published in 1924 where a risk of spontaneous rupture would exist when less than 50% of the tendon remains undamaged. Our objective was to analyze the mechanical behavior of cadaveric peroneal tendons subjected to an artificially made damage, compromising 66% of its visible width and tested in a cyclic and failure phase. Our hypothesis was that no failure would be observed in the cyclic phase.

Methods:

8 cadaveric foot- ankle – distal tibia specimens were included in this study. A longitudinal full thickness tendon defect was created, 3 cms in length, centered behind the tip of the fibula, compromising 66% of the visible width of the peroneal tendons as measured by a caliper. The peroneal retinaculum was kept intact. All specimens were mounted onto a special frame specifically designed for the study. All tendons were tested in a cyclic fashion using 100 repetitions between 50 N and 200 N. If no visual change or tendon failure was observed after the initial testing, a load to failure test was performed until tendon rupture or fixation failure was observed. Tendon stiffness and load to failure were registered. Statistical analysis was performed using the SPSS software.

Results:

No tendon failed during the cyclic testing. No defect lengthening was observed after the cyclic phase. On the failure phase, the mean load resisted by the peroneus brevis was 416 N, with a 95% confidence interval between 351 N -481 N. The mean load resisted by the peroneus longus was 723 N, with a 95% confidence interval between 578 N – 868 N. All failures were at the level of the defect created. The coefficient of variation was low for both tendons.

Conclusion:

A 33% of remaining peroneal tendon was able to resist very high tensile forces; therefore, it can be suggested that a 66% defect can be repaired and does not necessarily need a tenodesis as it has been historically recommended. The high resistance offered by the peroneus longus tendon offers the theoretical potential to use part of it as a free graft to repair peroneus brevis tears. The 50% rule, which determines when a peroneal tendon tear needs a tenodesis or repair, should be revisited.
Peri-talar Osteotomy as Part of Treatment of Talar Osteochondral Defect of Varus Ankle
Authors: Wang Bibo
Published: September 2017

Category:

Ankle

Introduction/Purpose:

The etiology of osteochondral defect (OCD) of talus is not fully understood. Besides trauma, malalignment of ankle or hindfoot may play a role in the development of OCD. The aim of this study is to assess the efficacy of peri-talar osteotomy in addition to routine treatment of OCD of talus.

Methods:

This is a retrospective study of 52 cases of varus talar OCD during the period of 2009.9 to 2014.12. Micro-fracture or autograft transplantation were applied for the OCD first according to the dimension of the lesion in all cases. Then peri-talar osteotomy were performed to correct ankle or hindfoot mal-alignment in 26 cases according to the position of varus deformity, including 18 supramalleolar osteotomy, 6 calcaneal osteotomy and 2 combined distal tibial and calcaneal double osteotomy. Pre- and post-operative radiographic parameters of TAS, TTS, TLS angles and MoA were measured on mortise view, lateral view and hindfoot alignment view respectively. AOFAS-AH score, VAS score and SF36 score were performed to assess both subjective and objective outcome.

Results:

For the osteotomy group, there were statistically changes (P < 0.05) radiographically (TAS, TTS, MoA, TLS) after surgery. While the radiographic parameters didn’t change in the group without corrective osteotomy. AOFAS-AH score and VAS score increased significantly (P < 0.05) in both the osteotomy group and the non-osteotomy group. The SF36 scores score increased significantly (P < 0.05) in the osteotomy group while not significant in the non-osteotomy group. The AOFAS-AH and SF36 scores were statistically higher in the osteotomy group after surgery (p<0.05), and the VAS score were not statistically different in two groups. There were 5 out of 26 revised cases in the non-osteotomy group while 2 out of 26 revised cases in the osteotomy group.

Conclusion:

Peri-talar osteotomy in addition to routine treatment of OCD of talus results in better radiographic and functional outcome and lower recurrence for patients of varus talar osteochondral defect. Mechanical malalignment may contribute to progression of OCD of talus and thus should be corrected simultaneously.
Effects of age and gender on gait characteristics using a wearable foot inertial-sensor device assessment
Authors: Angthong Chayanin
Published: September 2017

Category:

Gait studies

Introduction/Purpose:

This study is to determine the effects of age and gender on the gait characteristics using a wearable foot inertial-sensor assessment in the patients with foot and ankle conditions.

Methods:

There were 53 patients with foot and ankle-related conditions (38 females and 15 males, mean age: 51.4 (±14.0) years) who were collected for this study. For all patients, the clinical assessments, including the evaluations with validated patient- reported outcome using visual analogue scale foot and ankle (VAS-FA) score and health-related quality of life using validated Short Form-36 (SF-36), diagnoses, and gait characteristics assessment using a wearable foot device with the Micro electro mechanical systems (MEMS) inertial-sensor technology during patients’ walking trial for a distance of 10-meter at their self-selected speed. This device captures the gait parameters as distance walked, step counts or length, cadence, and walking speed. Foot Pod output can be wireless synced to a compatible smartphone or tablet. Pearson’s correlation coefficient r or Analysis of variance (ANOVA) tests were used to express the correlation between age and gait parameters or to compare the parameters between male and female groups.

Results:

There were insignificantly negative Pearson’s correlation coefficients r between age and walking speed or between age and cadence (P>0.05). Male patients had significantly higher maximum walking speed (P=0.015) and step length than female patients (P=0.011).

Conclusion:

In contrary to the previous study, the present study demonstrated that higher age had no effect on the reduction of walking speed. However, the effects of gender on gait characteristics were proved as higher maximum walking speed and step length in men.