bluuebunny/crossref_metadata_2025 huggingface dataset:
Relationship between Demographic and Radiographic Characteristics and 2nd Ray Pathology in Hallux Valgus Patients
Authors: Cronin Samantha , Conti Matthew S. , Williams Nicholas , Ellis Scott J.
Published: November 2020

Category:

Bunion; Midfoot/Forefoot

Introduction/Purpose:

Hallux valgus can alter load bearing in the foot and may result in secondary pathologies such as hammertoes of the second ray. However, there has been little research on the development of second ray pathology in patients with pre-existing hallux valgus. Additionally, most research examining these three-dimensional foot deformities relies on two- dimensional plain radiographs. The goal of this study was to determine if hallux valgus is associated with second ray hammertoes using three-dimensional weightbearing CT scans.

Methods:

71 patients who underwent a modified Lapidus procedure for hallux valgus and had preoperative weightbearing CT scans were separated into 2 outcome groups: (1) hallux valgus only (47 feet), and (2) hallux valgus with second ray hammertoe (29 feet). Preoperative age, BMI, sex, hallux valgus angle (HVA), intermetatarsal angle (IMA), absolute and effective first, second, and third metatarsal lengths, the ratios between metatarsal lengths, Meary’s angle, metatarsus adductus angle (MAA), and pronation were measured. Mean values of continuous variables were compared using one-way ANOVA tests or Kruskal-Wallis tests. Simple logistic regression models were created to evaluate associations between variables and hammertoe occurrence: (1) comparing hammertoe to hallux valgus only, (2) comparing hammertoe to hallux valgus with mild hammertoe removed, and (3) comparing hammertoe to hallux valgus with severe hammertoe removed. Multivariable logistic regression models were generated to evaluate potential risk factors for hammertoe after adjusting for patient age and BMI.

Results:

Patients in the hammertoe group were found to be significantly older and have significantly higher BMIs, HVAs, effective second MT lengths, IMAs, and more apex plantar Meary’s angles (all P-values < 0.05). BMI and HVA were also found to be significant predictors of second ray hammertoe in simple logistic regression models (OR=5.66 (95% CI: 1.67-22.79) and OR=4.5 (95% CI: 1.13-21.06), respectively). The multivariable analysis demonstrated that higher IMA and a more apex plantar Meary’s angle were the only significant predictors of second ray hammertoe risk (P= 0.03 and P = 0.01, respectively) once corrected for age and BMI.

Conclusion:

Significant associations were found between older age, higher BMI, and more severe deformity and the occurrence of hammertoe in hallux valgus patients. These relationships may aid in determining which patients are at a greater risk of progressing to secondary pathologies and which patients could potentially benefit from earlier surgical intervention to correct hallux valgus.
Contribution of First Tarsometatarsal Joint Fusion to Deformity Correction in the Treatment of Adult Acquired Flatfoot Deformity
Authors: Day Jonathan , Conti Matthew S. , Williams Nicholas , Ellis Scott J. , Deland Jonathan T. , Cody Elizabeth
Published: November 2020

Category:

Midfoot/Forefoot; Other

Introduction/Purpose:

Severe adult-acquired flatfoot deformity (AAFD) is often associated with painful medial column collapse at the naviculocuneiform (NC) joint. The purpose of this study was to examine the role of first tarsometatarsal (1st TMT) fusion combined with subtalar fusion in correcting deformity at this joint.

Methods:

We retrospectively analyzed 40 patients (41 feet) who underwent 1st TMT and subtalar (ST) fusion as part of a flatfoot reconstructive procedure. We assessed six radiographic parameters both preoperatively and at a minimum of 6 months postoperatively, including talonavicular (TN) coverage angle, lateral talo-first metatarsal angle, lateral talocalcaneal angle, calcaneal pitch, hindfoot moment arm, and a newly defined navicular-cuneiform incongruency angle (NCIA). Patient-Reported Outcomes Measurement Information System (PROMIS) clinical outcomes were assessed preoperatively and at a minimum 1 year follow-up.

Results:

The NCIA demonstrated excellent interobserver reliability, with no significant change between pre- and postoperative measurements. All other radiographic parameters, except calcaneal pitch, demonstrated statistically significant improvement postoperatively (p <0.01). Overall, patients had statistically significant improvement in all PROMIS domains (p <0.01), except for depression. Worsening NC deformity was not associated with worse patient-reported outcomes.

Conclusion:

Our data suggests that when addressing collapse of the medial arch in patients with AAFD, fusion of the 1st TMT joint in combination with other procedures leads to acceptable radiographic and clinical outcomes. There was no change in deformity at the NC joint at short-term follow-up, and patients achieved significant improvement in multiple PROMIS domains. Based on our findings, deformity through the NC joint does not significantly impact clinical outcomes. In addition, the NCIA was established as a reliable radiographic parameter that can be used to assess NC deformity in the presence of talonavicular and/or 1st TMT fusion. [Table: see text]
Perspectives From the Foot and Ankle Department at an Academic Orthopedic Hospital During the Surge Phase of the COVID-19 Pandemic in New York City
Authors: Day Jonathan , MacMahon Aoife , Roberts Matthew M. , Drakos Mark C. , Johnson A. Holly , Levine David S. , O’Malley Martin J. , Cody Elizabeth , Behrens Steve B. , Deland Jonathan T. , Demetracopoulos Constantine A. , Elliott Andrew J. , Ellis Scott J.
Published: November 2020

Category:

Other

Introduction/Purpose:

Cases of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus (COVID-19) first emerged in Wuhan, China, in December 2019. Since then, the virus has spread globally at a rapid pace. The first case in New York City was reported on March 1, 2020, and the World Health Organization (WHO) declared a pandemic on March 11, 2020. New York City rapidly became the epicenter of the pandemic, with hospitals across the city making a number of changes to accommodate the influx of COVID-19 patients. Here, we describe our experience in adapting to the COVID-19 pandemic as a department consisting of 10 foot and ankle fellowship-trained surgeons with up to 28 years of individual experience in an academic orthopedic hospital.

Methods:

Information was obtained from direct interviews with surgeons in the Foot and Ankle Service and from our institution’s intranet. Additional information was obtained by viewing twice-weekly livestreams from March 27th, 2020 to May 1st, 2020 held by the Surgeon-In-Chief, which detailed hospital-wide policies and initiatives being implemented in the wake of the COVID-19 pandemic.

Results:

On March 17, 2020, all elective surgeries were suspended at our institution, and a list of essential procedures was established. In-person clinical visits were limited to new patients being evaluated for essential procedures and first postoperative visits for returning patients, with all patients receiving pre-visit and on-site screening for COVID-19. All other new patient and follow-up appointments were conducted via telehealth visits. Much of our main hospital was repurposed to accept transfers of both COVID-negative and COVID-positive patients. A postanesthesia care unit and a floor of 9 operating rooms were repurposed as negative-pressure rooms for the care of critical COVID-positive patients on ventilators. An Orthopedic Triage Center (OTC) was established to relieve the patient load in the emergency departments of other hospitals in the city.

Conclusion:

By changing the way we delivered foot and ankle care and repurposing the roles of our employees and our institution, we have adapted strategies to continue delivering care to our patients. As we transition toward a ‘new normal,’ our goals are to gradually progress toward normal operations while keeping our patients and employees safe. With these gradual steps, we hope to emerge from this pandemic stronger and ready to adapt to the ever-changing needs of our community.
True Antiglide Fixation of Weber B Ankle Fractures has Lower Rates of Removal of Hardware
Authors: DeKeyser Graham J. , Kellam Patrick , Higgins Thomas F. , Rothberg David , Haller Justin , Marchand Lucas S.
Published: November 2020

Category:

Trauma; Ankle

Introduction/Purpose:

Plating of unstable OTA/AO 44-B1 lateral malleolus fractures has been associated with pain, peroneal irritation, and subsequent hardware removal. There has been speculation that this is due to the prominent plate and distal screw placement. Previous studies have looked at posterior vs lateral plate position but have had fairly low numbers in each group. The purpose of this study was to retrospectively compare the rates of hardware removal in unstable OTA/AO-type 44-B1 lateral malleolus fractures fixed with a posterior, true anti-glide plate with no screws in the distal segment versus those that were fixed with a similarly placed posterior, neutralization construct that included screws in the distal fragment thus evaluating the role of the distal screw in rates of hardware removal.

Methods:

Skeletally mature patients that were treated for an isolated OTA/AO 44-B1 fracture over a ten-year period (2007- 2017) were reviewed. Fractures treated with a single posterior plate were included and those fixed with a direct lateral plate were excluded. We evaluated post-op radiographs to determine application of a true anti-glide plate or a neutralization plate with screws in the distal fragment. Radiographic follow-up was used to determine bony union, malunion and need for hardware removal. Hardware removal was determined as entire plate removal; isolated syndesmotic screw removal was not included. Patients were excluded if they had less than six months of follow up. Relative risk was determined for the rate of hardware removal based on fixation technique.

Results:

There were 548 OTA/AO 44-B1 fractures treated over the course of ten years (2007-2017). After screening, 88 patients were included in the study. The majority of excluded patients lacked adequate follow-up. Average age of the cohort was 46 years old (range 17-84), with 47 females and 41 males included. Average length of follow up was forty months (range 6.1- 140.3). There were 28 patients in the true anti-glide plate group and sixty in the neutralization plate group. Five (18%) in the anti- glide plate group and 19 (32%) in the neutralization plate underwent a second procedure of hardware removal. Relative risk of hardware removal was 0.56 (95% CI 0.23-1.36, p=0.2). There was a 100% union rate with 0% malunion in both groups.

Conclusion:

Anti-glide plating has a near 50% relative risk reduction in the rate of hardware removal when compared to posterior based neutralization plating. Fractures fixed with or without distal screws had equivalent excellent results related to bony union and alignment. A true anti-glide plating construct should be considered as a safe and effective way of managing OTA/AO 44-B1 lateral malleolus fractures with a lower relative risk of a second operation for hardware removal.
Radiographic Outcomes of Intramedullary Fixation of the Distal Fibula in Unstable Ankle Fractures
Authors: Delman Connor , Saiz Augustine , Haffner Max , Arora Aman , Bhatti Satninderdeep , Giza Eric , Kreulen Christopher D.
Published: November 2020

Category:

Trauma; Ankle

Introduction/Purpose:

Intramedullary fixation of the distal fibula in unstable ankle fractures provides an alternative treatment strategy to traditional techniques and may reduce the complication profile. While often reserved for soft-tissue protection or elderly patients, the indications for this technique continue to expand. The purpose of this study was to evaluate the radiographic outcomes of ankle fractures treated with intramedullary fixation of the distal fibula with screw or flexible fixation of the syndesmosis.

Methods:

A retrospective case-series was performed of patients >18 years old with unstable ankle fractures treated at a single institution. Patients were treated with intramedullary fixation of the distal fibula and screw or suture-button fixation of the syndesmosis if indicated. Radiographic parameters measured included the medial clear space, tibiofibular overlap, tibiofibular clear space, talocrural angle, and fracture displacement. Fracture pattern, comorbidities, and postoperative complications were also assessed.

Results:

Fourteen patients (6 males, 8 females) with torsional ankle fractures (71% SER-IV patterns) were included in the study with a mean follow-up period of 5 months. Five patients had suture-button fixation and one patient had trans-syndesmotic screw fixation of the syndesmosis. All patients had improvement in radiographic parameters following surgical stabilization. Medial clear space decreased from a mean of 5.6 +- 3.1mm to 2.8 +- 0.79mm (p<0.0001). Tibiofibular overlap increased from 0.4 +- 2.7mm to 3.0 +- 1.5mm (p<0.05). Fracture displacement of the fibula decreased from 3.5 +- 1.8mm to 0.61 +- 1mm (p<0.0001). There was no statistically significant difference between preoperative and postoperative tibiofibular clear space and talocrural angle measurements. There were no lateral wound complications, revision surgeries, or hardware complications.

Conclusion:

This case-series demonstrates the successful use of intramedullary fixation of distal fibula fractures in unstable ankle injuries with good radiographic and clinical outcomes. The use of an intramedullary device does not preclude trans-syndesmotic screw or suture-button fixation of concomitant syndesmotic injuries. Orthopedic surgeons can consider this treatment strategy as an alternative to traditional techniques.
Treatment of Zone II and III Fifth Metatarsal Fractures Using a Novel Fixation Technique
Authors: Eble Stephanie K. , Hansen Oliver B. , O’Malley Martin J. , Drakos Mark C.
Published: November 2020

Category:

Sports; Lesser Toes

Introduction/Purpose:

Zone II and III 5th metatarsal fractures are common injuries which can be addressed surgically with percutaneous fixation following anatomic reduction. Limited vascular supply and the specific anatomy of the 5th metatarsal causes concern for non-union of these fractures. This study evaluated a novel screw designed to optimize 5th metatarsal fixation. The titanium alloy headless screw (Jones Union System, Extremity Medical, Parsippany, NJ) provides compression across the fracture site using variable angle pitch and is designed to minimize the occurrence of painful hardware. In addition, we use an intramedullary reamer to create local autologous bone grafting in conjunction with an osteoplasty of the cuboid to obtain ideal positioning. This study represents the first to evaluate clinical outcomes following fixation with this system.

Methods:

Patients treated for a 5th metatarsal fracture between 2018 and 2019 by two surgeons fellowship-trained in foot and ankle orthopedics were identified. Operative notes were reviewed to ensure that patients were treated with the headless compression screw. 21 patients (22 fractures) were identified. Postoperative x-rays were reviewed to evaluate osseous bridging and time to union was determined. Retrospective chart review was performed to determine time to return to sport. Postoperative complications, including non-unions, need for revision, and need for hardware removal, were also evaluated.

Results:

Of the 22 total fractures, 16 were Zone II fractures and 6 were Zone III fractures. Average time to clinical follow-up was 13.60 months (range, 3.91-25.07). Average age at time of surgery was 28.82 years (range, 16 to 66). 16 males and 5 females were represented with average BMI of 27.41 kg/m2. Average time to union was 6.78 weeks (range, 5.13-12.12), and average time to return to sport was 11.38 weeks (range, 5.87-15.12). No patients experienced a non-union or painful hardware, and no other postoperative complications were observed.

Conclusion:

Fixation of Jones fractures using the Jones Union System produced excellent postoperative outcomes. This system, designed to address the challenges of 5th metatarsal anatomy, demonstrated effectiveness with expeditious times to union and return to sport. Union rates were high, and our cohort did not experience any postoperative complications. Although follow-up in some cases is short, no patient has experienced painful hardware. Our results suggest that this system is an effective approach for fixation of Zone II and III 5th metatarsal fractures.
The Percutaneous Technique for the Treatment of Metatarsalgia with Metatarsophalangeal Dislocation of the Lesser Toes: Preliminary Results
Authors: Ferraz Gabriel F. , Santos Tatiana F. , Oksman Daniel , Filho Miguel V. Pereira
Published: November 2020

Category:

Lesser Toes

Introduction/Purpose:

Minimally invasive surgery through percutaneous technique has developed significantly in recent years, increasing its indication for correction of foot deformities, especially in the forefoot region. The treatment of severe metatarsalgia remains a challenge for surgeons, especially in techniques requiring larger incisions.

Methods:

We prospectively evaluated 16 patients diagnosed with metatarsalgia with plantar keratosis associated with metatarsophalangeal dislocation of the lesser toes submitted to surgical correction by the distal metatarsal metaphyseal osteotomy (DMMO) technique. Clinical (AOFAS, FFI and VAS) and radiographic scores were used, as well as personal satisfaction criteria. Statistical analysis was performed using the Mann-Whitney U test and Fisher’s Exact Test with the R software ‘Stats’ package.

Results:

One participant was lost to follow-up, totaling a sample of 15 patients and 16 feet (a bilateral case). The mean follow-up was 14 months (6 - 23) and the mean age of the sample was 73.53 (62 - 85). There was a significant reduction in postoperative status with a reduction in VAS of 5.47 (p <0.001) and a difference in metatarsalgia after the procedure, ranging from 100% of cases to 13% (p <0.001). All patients stated that they would do the procedure again if necessary and most (73%) defined it as satisfied with the procedure (Coughlin Score).

Conclusion:

The DMMO technique for the treatment of metatarsalgia in patients with metatarsophalangeal dislocation of the lesser toes has shown good results, reducing pain and high satisfaction index, demonstrated by preliminary results.
A Comparison of First Ray Length and Dorsiflexion after Arthrodesis, Osteotomy and Suture Button Procedures for Hallux Valgus Deformity
Authors: Foran Ian , Mehraban Nasima , Jacobsen Stephen K. , Bohl Daniel D. , Lin Johnny L. , Lee Simon , Holmes George B. , Hamid Kamran S.
Published: November 2020

Category:

Bunion; Lesser Toes; Midfoot/Forefoot

Introduction/Purpose:

Shortening and dorsiflexion of the first metatarsal are a known side effect of metatarsal osteotomies for hallux valgus (HV) deformity with the potential to cause transfer metatarsalgia. We compared the effect of the first tarsometatarsal joint arthrodesis (Lapidus), proximal lateral closing wedge osteotomy (PLCWO), and intermetatarsal suture button fixation procedures on the length and dorsiflexion of the first ray.

Methods:

We retrospectively evaluated 123 feet in 115 patients. The average age was 54. There were 106 females. Eighty-four feet had a Lapidus procedure, 14 had a PLCWO, and 24 had intermetatarsal suture button fixation. Digital radiographic measurements were made for pre- and postoperative hallux valgus angle (HVA) and intermetatarsal angle (IMA), absolute and relative shortening of the first ray, and dorsiflexion.

Results:

Preoperative HVA and IMA did not differ between treatment groups (p>0.05 for each). Similar corrections of HVA (30.1 to 12.3 degrees) and IMA (14.7 to 7.0 degrees) were achieved in all three groups (p>0.05). There were significant differences in absolute first-cuneiform-metatarsal length (FCML) between Lapidus (-1.5mm), PLCWO (-2.5mm), and intermetatarsal suture button fixation (+1.1mm) (p<0.05). There were also significant differences in relative 1st metatarsal shortening between Lapidus (0.32mm relative lengthening), PLCWO (1.05mm relative shortening), and intermetatarsal suture button fixation (1.24mm lengthening) (p<0.05). Average dorsiflexion differed between the Lapidus (1.95 degrees) and PLCWO groups (0.49 degrees) (p<0.05).

Conclusion:

The use of the intermetatarsal suture button fixation relatively lengthens the first ray, whereas the Lapidus and PLCWO shorten it. Dorsiflexion may be higher with Lapidus and osteotomy procedures. These findings may be helpful to explain postoperative symptoms of metatarsalgia and for the surgeon’s selection of the appropriate surgical technique for preoperative planning. [Table: see text]
A Retrospective Analysis of Results and Outcomes after Cadence Total Ankle Arthroplasty Implanted through the End of 2017
Authors: Fram Brianna R. , Rogero Ryan G. , Corr Daniel , Pedowitz David I. , Tsai Justin
Published: November 2020

Category:

Ankle; Ankle Arthritis

Introduction/Purpose:

Total ankle arthroplasty (TAA) is an increasingly popular operative treatment of ankle arthritis, due to its ability to decrease adjacent joint degeneration and preserve gait mechanics compared to ankle arthrodesis. However, ankle arthroplasty components have a shorter mean longevity then their hip, knee, or shoulder counterparts. The Cadence TAA entered clinical use in 2016 and was designed to address common failure modes of prior systems. We report here on radiographic and clinical outcomes and early complications of the Cadence TAA system at a minimum of 2 years follow-up.

Methods:

Patients who underwent primary Cadence TAA from 2016 through 2017 by one fellowship-trained foot and ankle surgeon were eligible. Exclusion criteria included prior ipsilateral ankle arthrodesis or arthroplasty and lack of followup. Chart review was performed for eligible patients to identify complications and reoperations. Patients were contacted to obtain Foot and Ankle Ability Measure (FAAM) Activities of Daily Living (ADL) and Sport subscores, SF-12 Mental (MCS) and Physical Health (PCS) subscores, and Visual Analog Scale (VAS) pain levels (rated 0-100). Scores were analyzed with 2-sided repeated measures T- tests, with P<0.05 as significant. A second, blinded, fellowship-trained foot and ankle surgeon evaluated followup 5-view radiographs of each ankle to measure range of motion (ROM), alignment, peri-implant osteolysis, and component loosening or subsidence. Subsidence or loosening were defined, respectively, as >2mm or >2⁰ change in position for the tibial component and >5mm or >5⁰ change for the talar component.

Results:

Sixty patients were included with mean age 64 and mean BMI 32.0. Thirty patients (50%) had concurrent other procedure(s). FAAM-ADL, FAAM-Sports, SF-12 PCS, and VAS pain scores all improved significantly at mean 2.24 years post-op (Table 1). Ten patients (6.7%) had operative complications requiring 15 surgeries (mean 265 days to first reoperation). Three patients (5%) required removal of one or both components, for 2-year implant survival of 95.0%. Two revisions were for infection and one for osteolysis. This produced a mechanical failure rate of 1/60 (1.7%). Radiographic analysis revealed average coronal alignment improved from 7.4⁰ from neutral preoperatively to 2.2⁰ postoperatively. Average ROM was 36.5⁰ total arc of motion. One of 38 (2.6%) had signs of peri-implant osteolysis, with no cases demonstrating loosening or subsidence.

Conclusion:

Two-year follow-up of the Cadence TAA system demonstrates mechanically stable implants resulting in improved patient function and preserved ankle range of motion. Outcomes compare favorably to those of other TAA systems at 2-year follow-up. Further radiographic and clinical follow-up are needed to evaluate implant longevity and long-term patient functional outcomes. [Table: see text]
Readability and Suitability of Patient-Reported Outcome Measures in Foot and Ankle Surgery: A Health Literacy Assessment
Authors: Freibott Christina , Shoap Seth C. , Vosseller J. Turner
Published: November 2020

Category:

Other; Ankle; Hindfoot; Midfoot/Forefoot; Trauma

Introduction/Purpose:

Health literacy is consistently reported as one of the best predictors of health status. This becomes even more important considering the complex medical information that is communicated to a patient during a clinical visit. Patient reported outcome measures (PROMs) are used on a standard of care basis in orthopedic surgery, and consistently included in research projects to elucidate meaningful clinical information. While there have been published assessments on the reading grade level of orthopedic PROMs in general, few address foot and ankle specific outcome measures. There have been no reports on aesthetic component of these PROMs, which have a major impact on readability. The purpose of this study is to report on the literacy, readability, and suitability of PROMs in foot and ankle surgery.

Methods:

A PubMed search was conducted to identify the most frequently utilized foot and ankle PROMs. Two recent systematic reviews identified 86 total PROMs in orthopedic surgery, 8 of which were foot and ankle specific. For the readability component, the Flesh-Kincaid reading grade level was assessed for each PROM. For the aesthetic component, the Suitability Assessment of Materials (SAM) was utilized to assess for content, literacy demand, graphics, layout, typography, learning stimulation, motivation and cultural appropriateness. SAM is a validated measure for analyzing print materials, and designate rankings of not suitable, adequate, or superior, based on results of the analysis. SAM scores were evaluated for all included PROMs by two investigators and averaged together for increased validity. Descriptive statistics were performed on all results. Statistical analysis was performed with SPSS Version 24.0.

Results:

The average Flesh-Kincaid grade for all PROMs was 6.12 (+-2.2, range 3.9-8.5). 5 of the 8 (62.5%) PROMs were at or below the AMA-recommended 6th grade reading level, with 6 of 8 (75.0%) below the NIH-recommended 8th grade reading level. The average SAM score for all included foot and ankle PROMs was ‘adequate,’ receiving a score of 1. 1 PROM was designated ‘not suitable,’ with the remaining 7 deemed ‘adequate.’ The area that scored the lowest on the SAM assessment was the ‘graphics’ section.

Conclusion:

The PROMs used in foot and ankle surgery perform well on the Flesh-Kincaid score in comparison to both the AMA and NIH reading grade level standards. The highest rating for the SAM score was average, indicating room for improvement in suitability. The inclusion of graphics and illustrations would make these scores more easily understood by patients, which can improve their healthcare experience and improve patient satisfaction and health outcomes.
Autologous Osteochondral Transplantation for Osteochondral Lesions of the Talus: Does Gender Impact Outcomes?
Authors: Gianakos Arianna L. , Okedele Olasunmbo , Flynn Sean , Kennedy John G. , DiGiovanni Christopher W.
Published: November 2020

Category:

Ankle; Arthroscopy

Introduction/Purpose:

Autologous osteochondral transplantation (AOT) is commonly used in the treatment of osteochondral lesions (OCL) of the talus. There is limited data comparing gender differences in the incidence, presentation, and outcomes following AOT. The purpose of this study is to compare these differences between male and female patients.

Methods:

Eighty-five consecutive patients who underwent AOT were retrospectively reviewed. Patients were divided into two groups based on gender. Demographic data and OCL defect characteristic data were recorded. Functional outcomes were assessed pre- and post-operatively using the Foot and Ankle Outcome Score (FAOS). The Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score was used to assess cartilage incorporation. The mean clinical follow-up was 47.2 months, with mean MRI follow-up of 24.8 months.

Results:

Fifty-five (65%) males and 30 (35%) females were included. OCL defect size was significantly larger in men (112.8mm2) when compared with women (88.7mm2) (p<0.0001). Male patients had a significantly longer duration of symptoms (p<0.001) and OCLs were more likely traumatic in nature (p=0.0006) when compared with female patients. Mean FAOS improved pre- to postoperatively from 50 to 81(P < .001) with a statistically significant increase in men (p<0.0001). The mean MOCART score was 82.1 and 86.7 in male and female patients, respectively (p<0.0001). Lesion size was negatively correlated with MOCART score (r = -0.36,P = .004). No differences were found in knee donor site morbidity, complication rate, or revision surgery.

Conclusion:

Our study demonstrates that male patients typically present with talar OCLs that are larger in size, traumatic in nature, and with longer symptom duration when compared with female patients. In addition, male patients had greater improvement in FAOS scores following AOT. Therefore, understanding these differences may influence the management and treatment of talar OCLs in male and female patients.
Outcomes Following Arthroscopy for Anterior Impingement in the Ankle Joint: Need for Gender as a Variable in Analysis
Authors: Gianakos Arianna L. , Ivander Axel , DiGiovanni Christopher W. , Kennedy John G.
Published: November 2020

Category:

Ankle; Arthroscopy

Introduction/Purpose:

To provide an overview of the clinical outcomes of arthroscopic procedures used as a treatment strategy for anterior ankle impingement and to determine if gender affects outcome.

Methods:

A systematic literature search of the Medline, Embase, and Cochrane databases was performed during June of 2019. The combination of search terms utilized included the following: ankle, impingement, syndrome, talus, compression, osteophyte, arthroscopy, surgery, procedures, and treatment. Two reviewers independently performed data extraction consisting of demographic data, intraoperative arthroscopic data, functional outcome scores, patient satisfaction, complications, return to play, and gender differences.

Results:

Twenty-eight articles evaluating 1,506 patients were included in this systematic review [Table 1]. Sixty percent and 14% of studies assessed anterolateral and anteromedial impingement, respectively. All studies (16/16, 100%) that evaluated functional outcome reported improvements in AOFAS, VAS, and FFI Scores [Table 2]. The average complication rate was 3.89% [Table 3]. Average return to sport was 8 months. The most common associated pathologies found during arthroscopic evaluation were synovitis, osteophytes, and meniscoid lesions. Four studies (15%) failed to report gender as a demographic variable. Only 5 (17%) studies reported gender analysis, with one demonstrating that male patients had worse outcomes at 6-year follow-up.

Conclusion:

Our systematic review suggests that arthroscopic treatment for anterior ankle impingement provides good to excellent functional outcomes and low complication rates in the majority of patients. However, current analyses lack outcome evaluations that compare male and female populations. Future studies should perform such assessments to determine whether gender differences play a role in outcomes following arthroscopic intervention. [Table: see text][Table: see text][Table: see text]
The Perceived Effectiveness of a Short-term Orthopaedic Foot and Ankle Mission Trip to Kenya
Authors: Gokcen Eric C. , Luginbuhl Joshua C. , Luginbuhl Joshua C.
Published: November 2020

Category:

Other

Introduction/Purpose:

Short-term surgical mission trips have become increasingly common, with many benefits seen by the hosts and the visitors when trips are done properly. However, few visitors ever attempt to measure the impact of their visit other than to list the surgeries that were performed. This study was performed to determine the perceived educational impact on orthopaedic attendings and residents of a Kenyan internationally accredited orthopaedic residency program and to determine the hosts’ opinions on the effectiveness of orthopaedic short-term trips.

Methods:

A survey was developed and distributed to four host attending surgeons and 9 host residents at the beginning of an orthopaedic mission trip. The visitors included four attending orthopaedic foot and ankle surgeons from various US sites, and two orthopaedic surgery residents from one US program. Using a scale from 1-10, with 1 meaning definitely No, and 10 meaning definitely Yes, hosts were asked if they felt there was a need for more foot and ankle training in Kenya. A post-trip survey was distributed to the host attendings and residents to determine perceived competency in five topics of foot and ankle pathology.

Results:

When hosts were asked if they felt there was a need for more foot and ankle training in Kenya, attendings responded an average 8.3, and residents 9.4. When asked if a short-term trip would improve foot and ankle care for the community, attendings responded 7.8, and residents 7.9. A post-trip survey was completed by one attending and 3 residents to determine their perceived competency in five topics of foot and ankle pathology. Overall, they averaged an increase of +2.0 on the scale in their competency for all topics. The highest increase was with ankle instability and hallux valgus at +3.0, and the lowest increase was with Achilles pathology at +0.75.

Conclusion:

The survey supported the hypothesis that short-term orthopaedic foot and ankle surgery trips to this program are helpful according to the hosts. Furthermore, understanding the competencies of the hosts can help the visitors develop more impactful teaching by focusing on the topics of need. Further studies such as this should be routinely performed with medical trips to help determine their effectiveness.
How Obesity Affects Need for Syndesmotic Fixation in Malleolar Ankle Fractures and Ankle Fracture Severity
Authors: Goodloe Jonathan B. , Caughman Alexander , Traven Sophia A. , Slone Harris , Gross Christopher E.
Published: November 2020

Category:

Ankle; Trauma

Introduction/Purpose:

Obesity affects lower extremity fracture care through increased mechanical loading and has subsequently been associated with higher complication rates following surgical management. However, the association between BMI and need for syndesmotic fixation in the setting of malleolar ankle fractures remains to be elucidated. Therefore, the primary objective of this study was to determine the risk of increased fracture severity and need for syndesmotic fixation as related to BMI.

Methods:

A retrospective analysis of the NSQIP database was performed for patients undergoing surgical fixation of isolated, closed ankle fractures. Patients were grouped by fracture pattern (uni-, bi- and trimalleolar ankle fractures with or without syndesmotic injury). Demographic data was collected and compared between groups and logistic regression analyses were used to assess the relationship between BMI and ankle fracture pattern. Risk factors for postoperative complications and prolonged operative time were also compared between groups.

Results:

A total of 15,841 patients (mean age 48.9 years) were identified for inclusion. Analyses revealed that BMI had a positive association with the incidence of open reduction and internal fixation of the ankle syndesmosis, but there was no association between BMI and malleolar fracture pattern.

Conclusion:

This study demonstrates that elevated BMI is associated with an increased need for syndesmotic reduction and fixation in malleolar ankle fractures. However, the data did not find conclusive evidence to suggest that obesity was associated with ankle severity when evaluating malleolar involvement. Further literature is needed to further delineate the relationship between obesity and ankle fracture pattern.
Radiographic Correction after Hallux Valgus Surgery: A Meta-analysis
Authors: Gross Christopher E. , Barg Alexej
Published: November 2020

Category:

Bunion; Midfoot/Forefoot

Introduction/Purpose:

There are over 100 different means by which to surgically correct hallux valgus. None have been proven to be more effective in radiographic correction over another. Frequently, recurrence is noted. There has been no large-scale meta-analysis of studies reporting radiographic outcomes of surgical treatment for hallux valgus deformity. The purpose of the meta-analysis was to pool data to see if certain osteotomies have higher complication or recurrence rates.

Methods:

We performed a meta-analysis of studies reporting the radiographic outcomes of surgical correction for hallux valgus deformity. We pooled the data of 287 studies since 1980 that met our inclusion criteria. We divided the surgical procedures into proximal-based osteotomies (PB, n=2047), shaft-based (SB, n=1569), and distal-based (DB, n=7835). We calculated the hallux valgus angle (HVA) and intermetatarsal angle (IMA) correction as well as metatarsal shortening, recurrence, and hallux varus after surgery. ANOVA analysis was used to compare the means among the groups.

Results:

A total of 287 treatment studies met the inclusion criteria. The pooled rates of HVA correction between the PB, SB, and DB were: 20.7, 20, and 16.8 degrees respectively (p=.0004). The pooled rates of IMA correction between the PB, SB, and DB were: 8.5, 7.3, and 6.0 degrees respectively (p<.0001).There was a significant difference among the groups with the development of hallux varus (p=.003) and with metatarsal shortening (p=.025). There was no difference in the rate of recurrence.

Conclusion:

Despite the large pooling of data, no consistent superiority of any corrective osteotomy stood out. Fortunately, there is no difference in the recurrence rate among the osteotomies. Further randomized studies could help elucidate the best surgery for each patient.
Independent Inter- and Intra-Rater Reliability of the New AO and Leonetti/Tigani Systems for Pilon Fractures based on CT-Scan
Authors: Guiloff Benjamin , Villa Andres , Ananias Joaquin , Mery Pablo , Ledermann Gerardo , Correa Ignacio , Palma Joaquin
Published: November 2020

Category:

Basic Sciences/Biologics; Trauma

Introduction/Purpose:

There is still no consensus regarding which is the best classification system for the management of tibial plafond fractures. The goal of this study is to perform a independent agreement evaluation to compare two recently published systems: Leonetti/Tigani and the new AO classification.

Methods:

Seventy-five patients with tibial plafond fracture and preoperative CT scan were included. Six raters with different level of expertise (two foot and ankle surgeons and three orthopedic surgery residents) classified the fractures using CT scans according to the morphological grading of both systems. The Leonetti/Tigani classification system considers four types (I, II, III and IV) and six subtypes (I, IIF, IIS, IIIF, IIIS, IV). The AO system considers three types (A, B, C) and nine subtypes (A1, A2, A3, B1, B2, B3, C1, C2, C3). After six weeks all cases were randomly re-evaluated by the same raters. The kappa coefficient (κ) was used to determine the degree of reliability.

Results:

Inter-observer reliability: strong using the Leonetti/Tigani classification system considering types, with a κ of 0,65 (0,60 - 0,69), and subtypes, with a κ of 0,62 (0,58 - 0,66). Reliability for the AO system was strong considering types with a κ of 0,72 (0,66 - 0,78), but moderate when including subtypes with a κ of 0,54 (0,50 - 0,57). Intra-rater reliability: Almost perfect using the Leonetti/Tigani classification considering both types and subtypes with a κ of 0,94 (0,88- 1,01) and 0,94 (0,89- 0,96), respectively. Reliability for the AO system was almost perfect considering types with a κ of 0,83 (0,75- 0,92), but strong when including subtypes with a κ of 0,61 (0,57- 0,66). No statistically significant difference between different levels of expertise.

Conclusion:

The system proposed by Leonetti/Tigani demonstrated a strong and almost perfect inter and intra-rater reliability, respectively. Although the new AO classification has a strong inter-rater reliability when including the main categories, it only reached a moderate reliability when including subtypes.
Biomechanical Results of Percutaneous Calcaneal Osteotomy using Two Different Osteotomy Designs
Authors: Gutteck Natalia
Published: November 2020

Category:

Hindfoot

Introduction/Purpose:

Percutaneous osteotomy of calcaneus has been proposed to reduce the complication rate and became more and more popular. The bone cut can be performed as a straight or chevron-like (V) osteotomy using a Shannon burr. Comparative studies of straight or V- osteotomy as like as one or two screws in percutaneous calcaneal osteotomies are missing in the literature

Methods:

The straight osteotomy (9 fresh-frozen specimens) and V- osteotomy (9fresh frozen specimens) was performed and the calcaneal tuberosity was moved 10 mm medially and slightly rotated. One 6,5 mm cancellous compression screw was used for osteosynthesis. Specimens were preconditioned with 100N over 100 cycles. The force was increased after every 100N by 100N from 200 to 500N. This was followed by cyclic loading with 600N for 500 cycles.

Results:

Despite the higher mean values of the group with V osteotomy, no significant difference was registered between the two groups regarding the stiffness at all force levels. A significant higher failure rate was observed in the group with straight osteotomy.

Conclusion:

The moderate correlation of bone density and stiffness in the V-group, and significantly lower failure rate with no secondary dislocation in fluoroscopy indicates the superiority of the V-osteotomy in the present study. Whether the demonstrated advantages can be reflected in clinical practice should be investigated in further studies.
Comparative Results of Percutaneous Calcaneal Osteotomy in Correction of Hindfoot Deformities
Authors: Gutteck Natalia
Published: November 2020

Category:

Hindfoot

Introduction/Purpose:

Calcaneal osteotomies are often required in correction of hindfoot deformities. The traditional open techniques as lateral or oblique incision are occasionally associated with wound healing problems and neurovascular injury.

Methods:

In a prospective study 122 consecutive patients who underwent a calcaneal osteotomy for hindfoot realignment treatment were included. 58 patients were operated using an open incision technique and 64 patients with 66 feet using a percutaneous technique. Clinical and radiological assessments were performed preoperatively, six weeks and one year postoperatively.

Results:

The AOFAS score and VAS improved in both groups postoperatively. The difference was not significant. The results of the radiological measurements pre- and postoperatively were not significantly different. No pseudarthrosis occurred in both groups. The comparison of both groups showed a significant lesser risk for wound healing problems in percutaneous group (B). The hospitalisation time was significantly shorter in the percutaneous group.

Conclusion:

Due to the excellent results with the percutaneous calcaneal osteotomy the authors feel encouraged to establish this procedure as a standard technique for calcaneus osteotomy at our clinic.
Trends in Total Ankle Replacement in Scotland
Authors: Ha Taegyeong T. , Senthil Kumar Chinnasamy , Ha Taegyeong T. , Higgs Zoe , Watling Chris , Osam Cemre Su. , Madeley N. Jane , Halai Mansur
Published: November 2020

Category:

Ankle Arthritis

Introduction/Purpose:

Total ankle replacement (TAR) is performed for post-traumatic arthritis, inflammatory arthropathy, osteoarthritis and other indications. The Scottish Arthroplasty Project (SAP) began collection of data on TAR in 1997. In this study, using data from the SAP, we look at trends in the use and outcomes of TAR in Scotland.

Methods:

We identified 499 patients from the SAP who underwent TAR between 1997 and 2015 with imaging available on the National Picture Archiving and Communication System (PACS). We identified, and looked at trends in, implant type over the following time periods: 1998-2005; 2006-2010 and 2011-2015. Age, gender, indication and outcomes for each time period were examined and also trends with implant type over time.

Results:

There were 499 primary TAR procedures with an overall incidence of 0.5/105 population per year. The peak incidence of TAR was in the 6th decade. The mean age of patients undergoing TAR from 59 years in 1998-2005, to 65 years in 2011-15 (p<0.0001). The percentage of patients with inflammatory arthropathy was 49% in 1998-2005, compared with 10% in 2011-2015. Subsequent arthrodesis and infection rates appeared to be higher during the first time period. The female to male ratio also changed over time. The incidence of TAR increased overall during the study period (r= 0.9, p=<0.0001). This may be due to a broadening range of indications and patient selection criteria, in turn due to increased surgeon experience and the evolution of implant design.

Conclusion:

This study examines a large number of TARs from an established national arthroplasty database. The rate of TAR has increased significantly in Scotland from 1997 to 2015. Indication and patient age has changed over time and this could potentially impact outcomes after ankle replacement.
3D Imaging for Hindfoot Alignment: A Comparative Study between MRI and Weight Bearing CT
Authors: Haldar Anil , Bernasconi Alessio , Junaid Syed E. , Welck Matthew J. , Saifuddin Asif
Published: November 2020

Category:

Hindfoot; Other

Introduction/Purpose:

Hindfoot malalignment is a common finding in multiple foot and ankle pathologies. In clinical practice, it is usually quantified through traditional weight bearing radiographs or, more recently, through cone beam weight bearing CT (CB- WBCT), which overcomes issues related to two-dimensional imaging. Interestingly, a few studies have suggested that hindfoot alignment can also be accurately assessed using non-weight bearing magnetic resonance imaging (MRI). The purpose of this study was to compare measurements of hindfoot alignment on non-weight bearing ankle MRI and CB-WBCT and to establish if there was any correlation.

Methods:

In this Level III retrospective comparative study, a database review identified 51 feet in 47 patients (27 males, 20 females; mean age of 45 (range 13-79)) which had both CB-WBCT and MRI scans on the same day as part of standard care at our specialist tertiary referral Foot and Ankle Unit. Hindfoot alignment was assessed by independent Consultant Musculoskeletal specialists. The foot ankle offset (FAO), calcaneal offset (CO) and hindfoot alignment angle (HA) were assessed on CB-WBCT using dedicated software. The tibiocalcaneal angle (TCA) and calcaneofibular ligament angle (CFLA) were assessed on non-weight bearing MRI. Pearson correlation was used to evaluate the correlation between these measurements.

Results:

We found a statistically significant positive correlation between TCA on non-weight bearing MRI and each measurement on CB-WBCT (Pearson correlation for TCA and FAO: 0.42, p=0.003; for TCA and CO: 0.46, p=0.001; and for TCA and HA: 0.40, p=0.005).We also demonstrated a moderate-to-low negative but significant correlation between CFLA and CO (Pearson correlation: -0.35; p=0.03). Conversely, the negative correlation between CFL and FAO (Pearson correlation: -0.29; p=0.07) and CFL with HA (Pearson correlation: -0.26; p=0.11) did not reach statistical significance.

Conclusion:

Weight bearing three-dimensional imaging has shown high degrees of accuracy and reproducibility for hindfoot alignment. The significant correlation between TCA on non-weight bearing MRI and hindfoot alignment measurements on CB- WBCT suggests that TCA should be reported during routine ankle MRI in order to put into context some of the soft-tissue findings. The CFLA shows a less significant negative correlation.