bluuebunny/crossref_metadata_2025 huggingface dataset:
Findings of Routine Diagnostic Ankle Arthroscopy for Management of AO 44-C Fibular Fractures
Authors: Dean Daniel , McGuigan Francis , Casscells Nicholas
Published: September 2017

Category:

Ankle, Arthroscopy, Trauma

Introduction/Purpose:

High fibula fractures, including Maisonneuve and Weber type C fractures are commonly associated with syndesmotic injuries resulting in subluxation and dislocation of the ankle. These injuries to the joint are rarely evaluated or addressed during operative fixation, which generally consists of open reduction internal fixation of the fibula with or without fixation of the syndesmosis. Chondral lesions and loose bodies in ankle fractures may predict a poor result and can be addressed using arthroscopy to avoid exacerbating articular damage. The purpose of this study is to identify the frequency and severity of articular pathology in Weber C and Maisonneuve fibula fractures.

Methods:

A single surgeon case series of operatively managed ankle fractures with arthroscopic assessment from 2011-2015 was retrospectively reviewed. Inclusion criteria were patients with AO 44-C ankle fractures who were aged >17 and underwent arthroscopic assessment of the ankle joint prior to open reduction and internal fixation. Patients were excluded from the series if they presented <2 weeks from the time of injury, had a pilon variant, or had incomplete medical records available. Demographic information on the patients including age, sex, and BMI were collected. Information on mechanism of injury was recorded. Operative reports were reviewed and the presence of chondral injury and loose bodies was recorded. Descriptive statistics were performed on the collected data.

Results:

18 patients (12 male, 6 female) with a mean age of 38.3 years (range 17-61; SD 13.9) were included in the case series. The average BMI 29.6 (SD 6.92). Five of the included fractures were Maisonneuve fractures while the remaining 13 were Weber C ankle fractures. The mechanism of injury of the fracture was low energy in 12, high energy in 1, and unknown in 5. On arthroscopic examination, 12 (66.7%) of the fractures were associated with full thickness articular cartilage injury requiring formal chondroplasty, 16 (88.9%) were associated with a minimum of partial articular damage, and only 2 (11.1%) had no articular damage identified on arthroscopy. Additionally, 12 (66.7%) had loose bodies that were removed during ankle arthroscopy.

Conclusion:

This study adds to a growing collection of literature concerning chondral injuries during ankle fractures. The data from this study suggest that AO 44-C fibular fractures are associated with a high rate of intraarticular pathology that can be effectively identified and managed during arthroscopy. Prospective studies are required to determine if there are therapeutic benefits to routine ankle arthroscopy in AO 44-C ankle fractures.
Occupational Outcomes Of Reconstructive Surgery For Adult Acquired Flatfoot Deformity
Authors: Finnern Michael , Anderson Claude , Ryan Paul
Published: September 2017

Category:

Hindfoot

Introduction/Purpose:

Reconstruction of a symptomatic adult flatfoot is an involved operation with a long recovery period. No previous studies have looked at the occupational or functional results of athletically active patients who have undergone this surgery. In the United States military, the rates of return to unrestricted active duty are unknown.

Methods:

A retrospective review of all active duty military patients who underwent a reconstructive surgery for adult acquired flatfoot surgery at a single institution from January 2001-2015 was performed. Surgical, inpatient, and outpatient databases were searched via CPT and ICD9 codes. Approximately 1300 cases with potential flatfoot reconstructive surgery were identified. Only those patients with the diagnosis of flatfoot treated with both a boney procedure and a soft tissue procedure were included. Patients had to have at least one year follow-up or follow-up to the point of maximum medical benefit as defined by the operative provider. Final disposition of the patients had to have been recorded in the medical record. Three possible outcomes were utilized in the review of this cohort: patient returned to duty without restrictions, patient returned to active duty with restrictions, or patient separated from active duty due all or in part to this medical condition.

Results:

Fifty patients met inclusion criteria. 30/50 patients (60%) remained on active duty with permanent duty restrictions, and only two of 50 patients (4%) returned to full duty without restrictions. 20/50 (40%) underwent a Medical Evaluation Board (MEB) to separate from the military. A difference was noted in terms of the hindfoot realignment procedure performed: the probability of an MEB is higher for those patients who had a lateral column lengthening procedure than those who were treated with a medializing calcaneal osteotomy.

Conclusion:

The sample size is the largest study to date of patients with surgical correction for symptomatic pes planus. The results demonstrate that a service member with symptomatic pes planus requiring surgery faces a 96% chance of failure to return to pre-injury level of function. While some (60%) were able to remain on active duty with restrictions, there is a 40% chance that service members will face separation from the military due to their foot pain. Furthermore, patients treated with a lateral column lengthening had a higher probability of being medically discharged than those who had a medializing calcaneal osteotomy.
Angiology of the Plantar Plate
Authors: Finney Fred , Khoury Basma , Scott Jaron , Kozloff Ken , Irwin Todd , Holmes James , Talusan Paul
Published: September 2017

Category:

Basic Sciences/Biologics, Lesser Toes, Midfoot/Forefoot

Introduction/Purpose:

Hammertoes, crossover toes, and claw toes are common deformities and can be a major source of pain and dysfunction. These deformities result from instability of the metatarsophalangeal (MTP) joint due to incompetence of the plantar plate and/or collateral ligaments. Non-operative management is the first line of treatment. When non-operative treatment is unsuccessful, surgical interventions have been described. Newer surgical techniques focus on performing anatomic repairs of plantar plates. The vasculature of the foot has been well studied, but the vascular supply of the plantar plate has not been described. This study presents a new technique for imaging the microvasculature of the lesser toe plantar plates through micro- computed tomography (micro-CT) in order to better understand tear pathology and the capacity of healing with plantar plate repairs.

Methods:

The posterior tibial and dorsalis pedis arteries of a fresh frozen human cadaver foot were dissected and cannulated at the ankle for perfusion distally. After administration of an anticoagulant, each artery was perfused with Microfil® Silicone Rubber, a contrast agent. The compound was then allowed to cure, and the foot was fixed in formalin. The foot was sectioned through the metatarsal shafts for imaging, and imaging of the lesser toe MTP joints was performed using a Bruker Skyscan 1176 micro-CT scanner at 18 micron slices. Computerized reconstruction of the images was performed for three dimensional visualization of the vasculature.

Results:

Post-perfusion imaging of the lesser toe MTP joints using micro-CT allows for visualization of the plantar plate microvasculature. Preliminary imaging suggests that micro-CT is a useful modality for analysis of the blood supply of the plantar plate.

Conclusion:

Anatomic repair of the plantar plate has become a viable treatment option for MTP joint instability. One important question that remains to be answered is whether plantar plate tears have the capacity to heal. We present a novel technique for imaging of lesser toe plantar plate microvascularity using micro-CT. Preliminary results of post-perfusion imaging of the plantar plate are promising for developing a better understanding of its blood supply. Further definition of the plantar plate vascular supply will help clinicians understand the capacity for healing after repairs and may provide some insight to the biological causes plantar plate tears.
Anatomic Structures at Risk When Utilizing an Intramedullary Nail for Distal Fibular Fractures
Authors: Goss David , Reb Christopher , Philbin Terrence
Published: September 2017

Category:

Ankle

Introduction/Purpose:

Distal fibula fractures are most commonly fixated with plate and screw constructs. Conversely, modern generation fibular intramedullary nails are load-sharing devices that offer rigid internal fixation via percutaneous technique with only transaxial screws residing subcuticularly. The relative risk of damage to nearby structures is well characterized for plate and screws constructs; however, no such data is available for fibular nails. As a result, the purpose of this anatomic study was to assess the relative risk to nearby anatomic structures when implanting a current generation retrograde locked intramedullary fibular nail.

Methods:

This was an IRB-exempt study. Ten human cadaveric lower extremities were instrumented with a contemporary retrograde locked intramedullary fibular nail with three distal locking and two syndesmotic fixation options. The cadavers were then dissected by a single experienced orthopedic foot and ankle surgeon in a standardized fashion. The shortest distance, in millimeters (mm), between the site of procedural steps and nearby named structures of interest (i.e. sural nerve, superficial peroneal nerve and the peroneal tendons) was measured and recorded. Levels of risk were then assigned based on observed distances as high (0 to 5 mm), moderate (5.1 to 10 mm) and low (greater than 10 mm).

Results:

The peroneus brevis tendon was at high risk when making the distal skin incision in all specimens (Table). When reaming and inserting the nail through the distal fibula aperture, the peroneus brevis was at high risk in 7 specimens. The peroneus longus tendon was at moderate to high risk when inserting both the proximal and distal syndesmotic screws in 9 specimens. The superficial peroneal nerve was at high risk when inserting an anterior to posterior distal locking screw in 7 specimens. The sural nerve was at low risk for all procedural steps. Of note, no structures were observed to have been directly damaged.

Conclusion:

The current findings indicate that strict adherence to sound percutaneous technique is needed in order to minimize iatrogenic damage to neighboring structures when performing retrograde locked intramedullary fibular nail insertion. This includes making skin-only incisions, thorough blunt spreading down to bone, and maintaining close approximation between tissue protection sleeves and bone at all times. The current findings indicate that the peroneal tendons and superficial peroneal nerve are at the highest risk, and should be considered when performing relevant clinical outcomes studies.
Location of Activation of Tarsal Joints on SPECT CT Scan Predicts Preoperative Functional and Pain Scores on Supramalleolar Osteotomy Patients
Authors: Gross Christopher , Knupp Markus , Hintermann Beat , Schweizer Christine , Hirschmann Michael , Rasch Helmut
Published: September 2017

Category:

Ankle, Ankle Arthritis

Introduction/Purpose:

Combined single-photon emission computed tomography and conventional computed tomography (SPECT/CT) is a hybrid imaging modality that shows a combination of metabolic and structural information about the ankle. Recently, its use has expanded for pre-operative evaluation of supramalleolar osteotomies (SMO) for asymmetric ankle arthritis. It is unclear if the location of bone scan activation in other locations in the hindfoot is related to pre and post-operative functional and scores. We hypothesize that uptake in specific locations within the hindfoot can be associated with worse pre- and post- operative functional and pain scores.

Methods:

85 pre-operative SMO patients with varus (37), valgus (41), or neutral (7) alignment of the hindfoot were assessed using SPECT/CT. The level of activation on SPECT/CT scans was measured. Activation was assessed on both the tibia and talus including the talonavicular, subtalar, calcaneocuboid joints and subfibular region. Pre- and post-operative functional and pain scores (AOFAS Hindfoot, FAOS, and VAS) were recorded for each patient at an average of 3.7 years post-operatively. We compared SPECT/CT imaging with pre-operative patient scores assuming equal group variance and used a Chi-square analysis to determine if failure can be related to having activation in other joints besides the hindfoot.

Results:

Those with talonavicular (6) activation had worse malalignment as measured by the AOFAS Hindfoot-A (alignment) subscore; they had worse a functional status as measured by the AOFAS-F (function) subscore. Patients with subtalar joint activation (10) had significantly worse (p<.05) pre-operative VAS pain scores. They also had worse AOFAS-F, AOFAS Hindfoot, and FAOS-S (symptom) scores. Those with calcaneocuboid activation (1) did not have any correlation to pre-operative pain or functional scores. Patients with subfibular impingement (7) had worse alignment based on the AOFAS-A scores. Patients with hindfoot joint activation did not have a higher rate of failure relative to other locations in the ankle. Activation in these areas were not associated with any post-operative functional or pain scores.

Conclusion:

Pre-operative SPECT/CT evaluation of the hindfoot before a SMO can be used to clinically correlate patient-specific factors such as pain and function in the pre-operative period. Results from this study provide prognostic information the locations of lesions that may cause patients more functional disability and pain pre-operatively and in the future.
MRI Utilization by Orthopaedic and Non-orthopaedic providers for acute or chronic ankle pain
Authors: Gross Christopher , Palanca Ariel , Chapin Russell
Published: September 2017

Category:

Ankle

Introduction/Purpose:

The use of MRI poses a significant expense in the ever-increasing cost of healthcare. The American College of Radiology (ACR) recommends obtaining ankle radiographs within 6 months prior to MRI in the assessment of patients with acute or chronic ankle pain. In this retrospective utilization study, we examine the compliance rate of both orthopedic and non-orthopedic providers at two academic centers. We hypothesize that there is an over utilization of resources by non- orthopaedic surgeons.

Methods:

We retrospectively reviewed 721 patient charts (4/2015-11/2016) who had an ankle MRI. We analyzed the preceding conservative management and subsequent non-operative or surgical care of the patient, and made note of the ordering physician and whether or not radiographs were obtained prior to ordering an MRI. We also performed an analysis of diagnosis and identified common diagnoses that were associated higher levels of non-compliance to the ACR criteria.

Results:

Overall, we determined that 222 of the 259 (85.7%) of the orthopedic providers obtained radiographs prior to MRI while only 271of 462 (58.7%) non-orthopedic providers followed these criteria (p<0.0001). In total, we found that 493 out of 721 (68.4%) providers ordered ankle radiographs prior to MRI. Among orthopedic providers showing non-compliance with the ACR criteria, the most common patient diagnoses were tendinopathy and not obtaining new radiographs when radiographs were older than 6 months. Among non-orthopedic providers, the most common diagnoses were edema and tendinopathy.

Conclusion:

We found that orthopedic providers adhered much more closely to the ACR criteria, and that there is a significant over-utilization of resources by all providers, with an overall inappropriate use percentage of 32.1%. Increasing the compliance rate could prove to be an effective mechanism for decreasing the cost healthcare in the treatment of ankle pain.
The Talar Body Prosthesis Treated End Stage Ankle Arthrosis
Authors: Harnroongroj Thos
Published: September 2017

Category:

Ankle Arthritis

Introduction/Purpose:

Ankle arthrosis creates patient disability. Ankle arthrodesis is treatment of choice which creates ankle stiffness and arthrosis of neighboring joints. Total ankle replacement can preserve ankle motions but the results at mid and long- term follow up needed further evaluation. Talar body prosthesis (TBP) can provide long-term satisfactory foot-ankle function of the ankle sustaining talar body damages. Due to ankle biomechanics is different to hip and knee joints. So, we inserted TBP for treating end stage ankle arthrosis. The present study evaluated outcomes at 5-10 years of follow up and described surgical technique.

Methods:

Between 2001 and 2011, the TBPs were inserted in 23 ankle arthrosis patients. The data were reviewed. We included grade 3 Bargon and Henkemeyer radiographic grading of ankle arthrosis and deformed talar body. The patient with neurological, hip, knee, mid-foot problems which impeded walking ability and age more than 70 were excluded. The patient consisted of 13 females and 10 males. Mean age at index operation and the latest follow up were 54.70 (39-70) and 61.17 (47-75) years old. Mean BMI at the latest follow up was 25.56 kg/m2 (21.89-29.76). Surgical technique included TBP insertion with addressing and applying tensor fascia lata at the articular end of distal tibia. Pre- and the latest follow up AOFAS (American Orthopaedic Foot and Ankle Society) ankle-hindfoot score and radiographs were reviewed. Neighboring joint arthrosis was evaluated by Kellgren-Lawrence radiographic system. The data was statistically analyzed.

Results:

Mean follow up duration was 6.48 years (5-10 years). All 23 TBPs maintained congruent talocrural joint. There was no prosthesis failure in term of subsidence into calcaneus and prosthetic stem perforation into talar head at the last follow up. No neighboring joint arthrosis occurred according to the radiographs. The mean range of motion of last follow up was 22.17° of plantar flexion (median 22°, ranged from 15° to 29°) and 0° to 5° of dorsiflexion. The patients could perform activity daily life. Mean AOFAS ankle-hindfoot score at preoperative period and last follow up were 40 points (Median 36, Ranged from 31 to 58) and 74 points (median 75, ranged from 61 to 83), respectively. The statistical analysis showed significant improvement of the score (p<0.001).

Conclusion:

TBP can provide satisfactory result of ankle-hindfoot functions at 5-10 years follow up. Advantages of the prosthesis over ankle arthrodesis and total ankle replacement included preservation of the ankle motion without neighboring joint arthrosis and no prosthesis failure.
Locked Dorsal Compression Plate Arthrodesis for Degenerative Arthritis of the Midfoot
Authors: Hirose Christopher , Coughlin Michael , Flint Wesley
Published: September 2017

Category:

Midfoot/Forefoot

Introduction/Purpose:

Midfoot arthrodesis remains a technical challenge. Little is known of the required magnitude of compression in order to obtain fusion. Multiple techniques have been reported, reflecting the difficulty of achieving a good result. These methods include an in situ bone graft dowel technique, dorsal staple, Kirschner wire, trans articular lag screw, and screw and plate fixation. More recently, dorsal hybrid plating, and slot graft inlay arthrodesis have been described. The purpose of this study is to describe the results of a dorsal fixed-angle locking compression plate in the setting of multiple-joint midfoot arthrodeses.

Methods:

A retrospective study was performed to identify 62 consecutive patients who underwent midfoot arthrodeses from June 2009 to May 2016. A total of 184 joints were spanned by dorsal fixed angle locking compression plates. The medical risk factors, etiology of arthritis, body mass index, time to union, visual analog pain scores (recorded preoperatively and postoperatively), and post-operative complications were evaluated. Patients were followed for one year. Radiographs were read by two fellowship-trained surgeons to determine the time to fusion. If union was indeterminate, a computed tomography scan was obtained, with the presence of 50% or greater bridging bone as the definition of fusion.

Results:

Of the joints spanned, 156 fused (83%). The average time to fusion was 19.6 weeks (Standard Deviation 21 weeks). Complications included persistent numbness (10), wound infection (2), and deep venous thrombus (1). The average VAS score diminished from 5.9 preoperatively, to 1.7 at week 6, 1.9 at week 12, 2.6 at month 6, and 3.1 at one year.

Conclusion:

Despite the difficulty of midfoot arthrodesis procedures in obtaining solid fusion, the dorsal fixed angle locking compression plate demonstrates a union rate, time to fusion, and complication rate that is comparable with the existing literature. The results of this study also indicate room for improvement in the design of advanced plating systems, which could incorporate more uniform joint compression combined with biologic augmentation in the hope of achieving improved radiographic and clinical results.
Optimization of the Staged scheme for the Treatment of complicated (OTA C3) Tibial Pilon Fractures
Authors: Hui Zhang
Published: September 2017

Category:

Ankle, Ankle Arthritis, Arthroscopy, Bunion, Hindfoot, Lesser Toes, Midfoot/Forefoot, Trauma

Introduction/Purpose:

To explore and evaluate the optimization operative strategy reported on our results using a direct approach with posterior malleolar plating in combination with staged anterior? xation in complex pilon fractures.

Methods:

43 patients were diviede into group A (23 cases, posterior plating and external? xator for stage I, ORIF through anterior approach for stage II)and group B(20 cases, closed reduction and external? xator for stage I, ORIF through anterior- posterior approach for stage II) between 2013 and 2014. With an average follow-up of 16.6 months,

Results:

The statistics showed that there were statistically significant differences (P<0.05)between two groups in the time before definitive surgery and the operative time of the stage II surgery, but in the time before initial surgery and the operative time of the initial surgery(P>0.05). The AOFAS and MLFAS scores in the group A were better than (P < 0.05) the Group B. 4 patients in the group A had some evidence of symptomatic arthrosis compared with 6 in the group B. The rate of tourniquet paralysis for the group A was 4.35% versus 35% (P < 0.05) for the Group B.

Conclusion:

The optimization operative strategy offers direct visualization for reduction, and allows the anterior components to be secured to a stable posterior fragment at a later date. The staged strategy not only obtains the leg fascia chamber decompression, also shortens the waiting time for operation, reduces reduction difficulties in definitive operation.
Measuring Visualized Tendon Length in Peroneal Tendoscopy
Authors: Hull Michael , Campbell John T. , Cerrato Rebecca , Jeng Clifford , Henn R. Frank
Published: September 2017

Category:

Arthroscopy, Sports

Introduction/Purpose:

Tendoscopy is a relatively new method of evaluating for tendon lesions in foot and ankle surgery. Despite multiple studies describing peroneal tendoscopy use, no study exists to determine the efficacy of tendoscopy at visualizing the entire length of the peroneal tendons. The purpose of this cadaver study was to measure the length of the peroneal tendons that could be visualized using tendoscopy

Methods:

Ten (10) fresh cadaveric specimens, complete above- or through-knee specimens, were evaluated. Peroneal Tendoscopy was performed with routine portal placement including proximally 2 cm above the lateral malleolar tip and mid- tendon proximal to the peroneal tubercle. For the initial 5 specimens, the peroneus longus sheath was entered distal to the tendon bifurcation and proximal to the lateral cuboid under direct visualization for zone 3 tendoscopy. For the subsequent 5 specimens, a more distal point closer to the base of the 5th metatarsal was used as a landmark for skin incision and the sheath was entered at the distal aspect of the cuboid. The edges of visualized longus and brevis tendons were marked with kirschner wires placed through the tendon percutaneously under direct visualization. The tendon sheaths were then dissected and the distances from anatomic landmarks were directly measured.

Results:

Proximally (zone 1), both the peroneus tendons were followed circumferentially to the musculotendinous junction of the longus in all specimens. Peroneus brevis was visualized in zone 2 to an average of 19.5 mm (95% CI 16.5-22.5) from its insertion onto the base of the 5th metatarsal. Using a peroneal tubercle start point, zone 3 of peroneus longus was visualized up to an average of 17 mm (11-23) from its insertion onto the base of the 2nd metatarsal. Using a more distal start point, longus was seen up to 1.6 mm (0.3-2.9) from its insertion. The muscle belly of peroneus brevis ended an average of 1.9 mm (-3.7-7.3) above the tip of the lateral malleolus.

Conclusion:

The results suggest that the vast majority of the peroneal tendons can be visualized during peroneal tendoscopy. It was also noted that a more distal skin portal site may improve visualization of zone 3 of peroneus longus.
Sinus Tarsi Volume Changes with Hindfoot Position on Weight-Bearing CT Scan
Authors: Hull Michael , Rutherford Tyler , Jeng Clifford , Campbell John T. , Cerrato Rebecca
Published: September 2017

Category:

Basic Sciences/Biologics, Hindfoot

Introduction/Purpose:

Sinus Tarsi syndrome is a frequent cause of anterolateral foot pain following injury. Chronic lateral subtalar pain, often referred to as “Sinus Tarsi Syndrome”, is commonly reported to occur following trauma. One hypothetical epidemiological predisposing factor for sinus tarsi syndrome is flatfoot deformity with valgus hind foot alignment. Common conservative treatment includes medial heel posting to attempt to widen the sinus tarsi space and alleviate synovitic pain. Although treatment with operative intervention has been reported, no data exists to evaluate if hindfoot realignment functionally opens the sinus tarsi volume.

Methods:

Weight-bearing Computed Tomography (CT) scans were obtained in 5 healthy volunteers standing at rest on slanted platforms, 25 degree valgus and 25 degree varus. The volume of the sinus tarsi was measured on each scan. Cross sectional area of the sinus tarsi was measured in 3.6 mm slices from the most lateral fully enclosed image to the most lateral aspect of the middle facet of the subtalar joint. Area measurements were multiplied by cut depth (3.6 mm) and summed. Critical angle distance was measured as a straight line from the most lateral point of the lateral process of the talus to the base of the critical angle of Gissane. Subfibular distance was then measured from the most distal tip of the fibula in a straight line to the nearest point of the lateral calcaneal wall. Data were compared using a one way ANOVA and Tukey’s multiple comparison test.

Results:

The mean sinus tarsi volume in the valgus position was 325.1 mm3 (±88) and 313.3 (±71) for the left and right foot, respectively. In the varus position, the mean sinus tarsi volume increased to 646.8 mm3 (±169) and 599 mm3 (±203). There was a significant difference between the varus and valgus position for both feet (left p<0.01 / right p<0.05). The critical angle distance increased from 28.1 mm (±7.5) to 91.3 mm (±26) for the left foot and 26.3 mm (±7.6) to 87 mm (±27.9) for the right foot when realigned to the varus position (p<0.0001). There was not a significant increase in the sub fibular distance when repositioned from valgus to varus (p=0.06 / p=0.35).

Conclusion:

This study confirms that moving from a valgus to a varus position significantly increases the volume of the sinus tarsi as well as significantly increases the distance from the lateral process of the talus to the calcaneal angle of Gissane. Interestingly, subfibular distance did not significantly increase, although this may reach significance with increased samples. With confirmation that adjusting hindfoot positioning impacts lateral osseous impingement, future studies are warranted to correlate these findings with clinical symptoms.
Achilles Tendon Repair- A Systematic Review of Overlapping Meta-Analyses
Authors: Hurley Eoghan , Yasui Youichi , Gianakos Arianna , Seow Dexter , Kromka Joseph , Shimozono Yoshiharu , Megill Robin , Kennedy John
Published: September 2017

Category:

Sports

Introduction/Purpose:

Acute Achilles tendon ruptures (ATR) are a common sports-related injury with an incidence of between 8-37 per 100,000 per year. While there are several meta-analyses published on the optimal treatment of ATR based on randomized control trials, the reported outcomes conflict between each meta-analysis due to different methodologies. The aim of this study is to systematically review the clinical results represented in meta-analyses in the current literature on acute ATR.

Methods:

Two independent reviewers performed the literature search based on the PRISMA guidelines to identify meta-analyses on Achilles tendon repair. Clinical results, including the re-rupture rates, wound infection rates and overall complication rates were analyzed. Level of evidence (LOE) and methodological quality of evidence (MQOE), using the AMSTAR score, were evaluated. A statistically significant difference (SSD) was defined as p < 0.05. Each meta-analysis was categorized into one of the following subgroupings: 1) Operative vs Non-Operative Treatment (with Conservative Rehabilitation) [OC vs NOC], 2) Operative vs Non-Operative Treatment (with Functional Rehabilitation) [OF vs NOF], 3) Conservative Rehabilitation vs Functional Rehabilitation (with Operative Treatment) [OC vs OF], and 4) Open vs. Percutaneous Repair (with Conservative Rehabilitation) [OC vs POC].

Results:

Four studies compared OC and NOC. Re-rupture rates ranged from 3.1-6.4% in OC and 10.0-13.0% in NOC. Two of these studies showed statistical significance in favour of OC. There was no SSD was seen in other complications. Three studies compared OF and NOF. Re-rupture rates ranged from 3.8-5.0% in OF and 6.0-11.9% in NOF, no study showed a SSD. There was no SSD in other complications. Three studies compared OF and OC. Re-rupture rates ranged from 2.13-3% in OF and 1.1-2.1% in OC, no study showed a SSD. Four studies compared OC and PSC. Re-rupture rates ranged from 2.2-4.4% in OC and 1.1-2.1% in PSC, no study showed a SSD. In all included studies there was SSD in wound infection rates, in favour of PSC.

Conclusion:

Overall there exists a large volume of high quality meta-analyses on Achilles tendon repair. The re-rupture rates were lower in operative treatment in all studies, even when early functional rehabilitation was used. However, while early functional rehabilitation may allow early mobility but the rehabilitation method can be demanding. Although there was no difference between percutaneous and open repair on the re-rupture rate, there was an overall reduction in wound infection after percutaneous repair. The results within this study can help determine the optimal treatment for patients.
Clinical Efficacy of a Kaolin-impregnated Dressing for Hemostatic Control in Diabetic Foot Ulcer Patients Receiving Anticoagulant Therapy in an Outpatient Clinic
Authors: Hwang Yeokgu , Park Yoo Jung , Shim Dong-Woo , Lee Jin Woo , Han Seung Hwan
Published: September 2017

Category:

Diabetes

Introduction/Purpose:

Orthopedic physicians encounter many diabetes patients who receive anticoagulant treatment because vascular diseases are the chief causes of death and disability in these patients. In these patients, if surgery or other procedures are required, it is still unclear whether anticoagulation therapy administration should continue. After discontinuation of anticoagulation therapy, the risk of cardiovascular complications is increased, although complications of bleeding after surgery are decreased; this is a dilemma in the treatment of diabetic foot ulcer. The purpose of this study was to examine the effectiveness, safety, and hemostatic effect of kaolin-impregnated gauze on diabetic foot ulcer patients who continue to receive anticoagulants after surgical debridement.

Methods:

Twenty patients receiving anticoagulant medication with diabetic foot ulcers requiring surgical debridement were enrolled. Diabetic foot ulcers were treated using surgical debridement and a basic dressing protocol, which involved direct application of the dressing material to the wound bed. For the study group, a kaolin-impregnated dressing was used, and dry gauze was applied to patients in the control group. Patients were randomly assigned to either group, and we compared hemostatic efficacy and adverse effects between the two groups. The presence or absence of hemostasis was assessed 5 and 10 minutes after dressing application. Treatment was considered successful if bleeding ceased adequately and no extra hemostatic measures were required within 10 minutes.

Results:

In the 20 patients undergoing surgical debridement, there was no evidence of bleeding within 10 minutes of dressing application. Eight of the 10 patients treated with a kaolin-impregnated dressing achieved complete hemostasis within 5 minutes. Five of the 10 patients in the control group failed to achieve hemostasis within 10 minutes. No adverse effects were noted.

Conclusion:

The use of a kaolin-impregnated dressing appears to be a safe, feasible, and beneficial option for the management of diabetic foot ulcer patients with a high risk of bleeding.
Middle and Long -term Clinical Results of Dorsiflexion Osteotomy for Severe Hallux Rigidus
Authors: Ikezawa Hiroko , Usami Norio , Hiraishi Eiichi , Takahiro Yamada
Published: September 2017

Category:

Bunion

Introduction/Purpose:

Total arthroplasty or arthrodesis is often used as a surgical procedure for severe case of hallux rigidus. However, because these procedures involve problems such as loss of joint function, age, and postoperative motion restriction, joint-preserving surgery is desirable for achieving a better quality of life. To resolve these problems, we have performed dorsiflexion osteotomy of the first metatarsal head since 2000, yielding favorable outcomes. We report about middle to long-term follow-up for our clinical results and radiographic findings.

Methods:

The study involved 31 feet of 30 patients (20 male,11 female) with Grade 2 (joint space narrowed to about 1/2 or less) or Grade 3 according to the Hattrup and Johnson classification. The mean age at surgery was 61.6 years (range: 53-77). Surgical techniques: We have used dorsal approach and conducted closed wedge osteotomy of the first metatarsal bone neck. Then, the bone head was flexed dorsally to form an articular surface and fixation. PWB was permitted 3 weeks after surgery. Mean postoperative follow-up period was 4 years and 2 months (range: 3-13 years). Clinical outcomes, range of motion (ROM), and radiographic findings were investigated.

Results:

Clinical outcomes were rated as excellent in 24 feet, good in 7, and fair/poor in none. All patients returned to normal daily life. Stiffness while walking was noted in 10 feet. As for ROM, most patients had a 1/2 to 2/3 of the normal range. No complications such as infection, nonunion, or transfer metatarsalgia were seen in any case. An X-ray film showed joint space narrowing in about half of all cases. None of the patients experienced pain relapse requiring arthrodesis again.

Conclusion:

The mechanism of pain relief is Dorsiflexion osteotomy is by bone shortening, make a decreasing joint pressure and regaining of normal articular to the dorsal side so that it faces the articular surface of the proximal phalanx. The postoperative restriction of ROM may be attributable to changes in the bone alignment and in the tension of soft tissue around the joint as compared to the healthy condition. None of the patients experienced pain relapse. Our procedure appears to be useful as joint- preserving surgery for severe cases with hallux rigidus.
Lateral talocalcaneal ligament substitution for calcaneofibular ligament difficient chronic ankle lateral instability
Authors: Jiao Chen
Published: September 2017

Category:

Ankle, Hindfoot, Sports, Trauma

Introduction/Purpose:

Introduction: Treatment of chronic ankle lateral instability associated with defective calcaneofibular ligament via tendon reconstruction or artificial grafts has several disadvantages. The method of substitution with lateral talocalcaneal ligament has never been reported. Purpose: To investigate the role of lateral talocalcaneal ligament substitution for the treatment of chronic ankle lateral instability associated with defective calcaneofibular ligament.

Methods:

Repair of ankle lateral ligament was performed on 32 patients with chronic ankle instability. The mean age was 26.4±8.7 years. The calcaneofibular ligament was absent in all the patients and was confirmed surgically. The calcaneofibular ligament was repaired via transfer of talar insertion of the lateral talocalcaneal ligament. Patients were followed up for an average of 22.3±4.0 months. AOFAS, Mazur and Tegner scores, objective examinations (anterior drawer test and varus stress test) and re-injury were assessed before and after the operation. The anterior translation distance of the talus and the talar tilt angle were also measured.

Results:

In all the patients, postoperative AOFAS, Mazur and Tegner scores were significantly improved. Postoperative evaluation (drawer test and lateral stress test) yielded negative results. The anterior translation distance was reduced from 4.9±1.0 mm to 2.0±0.8 mm. The talar tilt angle was reduced from 12.7º±2.5º to 5.0º±1.4º. The average satisfaction score was 7.4. No subjective instability or re-injury, subtalar joint (tarsal sinus) pain or/and instability occurred.

Conclusion:

Lateral talocalcaneal ligament substitution was effective against chronic ankle lateral instability associated with the absence of calcaneofibular ligament, without any significant effect on subtalar joint clinically.
What Kind of Procedure Should be Indicated for the Comminuted Talar Fracture as Initial Treatment?
Authors: Katsui Ryuhei , Takakura Yoshinori , Samoto Norihiro , Taniguchi Akira , Tanaka Yasuhito
Published: September 2017

Category:

Trauma

Introduction/Purpose:

Open reduction is most difficult to perform in comminuted talar fractures, because it necessitates osteotomy of the lateral or medial malleolus. Furthermore, the incidence of aseptic talar necrosis after a comminuted fracture is extremely high. Fifty-seven tali in 55 patients with aseptic necrosis of the talus underwent replacement with an artificial ceramic whole talus from 2005 to 2015, and we obtained excellent and good results. Based on the results, we performed replacement with an artificial ceramic talus, as the initial treatment, for 6 patients with comminuted talar fractures with bony destruction or defects.

Methods:

From 2009 to 2016, six feet in 6 patients with comminuted talar fractures were replaced with ceramic whole-talus prostheses as the initial treatment. Of them, 5 were male and one was female, with a mean age of 40.3 years (range, 19–59 years). The causes of the fractures were fall from a high place in 2 patients and traffic accident in 4. The ceramic prosthesis was made based on the computed tomographic scan of the normal opposite talus. The production of the custom-made prosthesis required a period of 5 weeks. In 3 patients, the capacity of the original talus was acquired by external fixation before replacement. Plaster cast immobilization was retained for 2 weeks each of non-weight bearing and weight-bearing. Preoperative and postoperative assessments were performed in accordance with the American Orthopaedic Foot and Ankle Society ankle/hindfoot score system.

Results:

Follow-up was conducted for 12 to 84 months (mean, 53.8 months). The postoperative AOFAS score was 68-100 (mean, 81.8). The result of the replacement with ceramic whole-talus prosthesis was excellent in 4, good in one, and fair in one. Three patients had resumed participation in sports activities (golf, aerobics, and jogging). However, 2 patients with open fracture and bony defects had limitation of the range of motion of the ankle. The patient with a fair result is still undergoing therapy for femoral and tibial fractures.

Conclusion:

A ceramic whole-talus prosthesis was used to replace 6 comminuted talar fractures as the initial treatment. The results using these prostheses were excellent, and good except one patient with open fracture and bony defects. Replacement with a ceramic whole-talus prosthesis should be indicated for comminuted fractures with bony destruction or defects.
The result of the treatment in osteoporotic ankle fractures with small fragment using claw plate in elderly
Authors: Kim Jun-Beom , Park Byeong-Seop , Ahn Chi
Published: September 2017

Category:

Ankle, Trauma

Introduction/Purpose:

Osteoporotic fractures in ankle have often included small bone fragments and were very unstable. There had been tried to fix them for anatomical reduction, using variable methods. However, it was not easy to keep the reduction, especially in elderly. The purpose of this study was to evaluate the results of the treatment in ankle fractures with small fragment using claw plate in elderly.

Methods:

The nineteen patients with ankle fractures, which included the small fragments, from january 2012 to july, 2014 were evaluated retrospectively. All patients were more than 65 years and had osteoporosis. The authors have been tried to fix it using claw plate in all cases. The mean follow up period was 15 months(range, 12month to 18month). The claw plate was designed to catch the small fragment and made of tubular plate or locking tubular plate with bending it after cutting the distal end of them. It had two different hooks to keep the reduction and the fragment. Functional outcome scores were obtained using Olerud Molander Ankle score(OMA), VAS, and American Orthopedic Foot and Ankle Society (AOFAS) score at 2, 3, 6, 9, 12 month after the operation, when each patient underwent a physical examination and radiography. There was evaluated statistically by SPSS 19.0

Results:

There were no complication, such as metal failure and loss of reduction. AOFAS score improved from 56.4±3.1 at 2 month to 93±1.5 at 12 month(p=0.01). The VAS improved from 6.2±0.9 at 2 month to 1.2±0.8 at 12 month(p=0.001). OMA score improved from 15.5±0.2 at 2 month to 75±2.5 at 12 month (p=0.001). There was significant difference, statistically. There was obstained the bony union in 3 months after the operation in all cases

Conclusion:

We suggested that the claw plate is the alternative method to fix the osteoporotic ankle fracture with small fragments in elderly, without complications
Radiological and clinical outcome of lateral ankle instability with medial compartment osteoarthritis
Authors: Kim Sungwook , Jung Hong-Geun , Lee Jong-Soo , Kang Hwa Jun , Sun Mao Yuan
Published: September 2017

Category:

Ankle, Ankle Arthritis, osteoarthritis, ankle instability

Introduction/Purpose:

When lateral ankle instability (LAI) is not treated for long period, unbalanced loading on medial ankle may proceed to osteoarthritis (OA). Outcome studies about osteoarthritis with lateral ankle instability after stabilization, however, have rarely been reported. The authors have investigated the radiological and clinical outcome of ligament stabilization for LAI with medial compartment OA.

Methods:

The study is based on 25 ankles of LAI with medial compartment ankle OA that underwent lateral ankle ligament reconstruction from 2007 to 2014 with at least 1 year follow-up. The medial ankle OA was diagnosed with degenerative change of medial ankle on plain X-ray or MRI or arthroscopic findings. The OA was classified using Takakura stage, and arthroscopic degenerative change was classified by modified Outerbridge grading. Ligament stabilization surgery was done using either modified Broström procedure or lateral ligament reconstruction using semitendinosus tendon allograft. Arthroscopic synovectomy, debridement, and microfracture for osteochondral lesion were performed when needed. Clinical outcomes were evaluated using visual analogue scale (VAS) pain score, American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, Karlsson- Peterson score, and subjective patient satisfaction. Statistical analysis were done using Wilcoxon signed rank test.

Results:

The average instability duration was 98 (range, 12-480) months and the average follow up period was 46 (range, 13-108) months. Preoperative Takakura stage was mostly I (n=19, 76%) and II (n=4, 17%), and was same postoperatively. MRI OA findings of 18 ankles were medial cartilage denudation (17%), cartilage thinning/erosion (44%), medial osteophyte (50%), and loose bodies (30%). Modified Outerbridge grade 2 and 4 were most common (both 41%). The VAS pain score decreased from 6.1 ± 1.6 preoperatively to 1.8 ± 1.6 postoperatively (P<0.05). The AOFAS score improved from 61.8 ± 14.7 preoperatively to 90.0 ± 6.3 postoperatively, and the Karlsson-Peterson score improved from 54.5 ±14.4 to 89.4 ± 8.4 (P<0.05). There were no significant complications. All patients were satisfied.

Conclusion:

Ligament stabilization accompanied with arthroscopic procedure could draw good outcome, even without structural bony deformity correction. Even with no improvement in plain radiograph, functional score could be improved.
Can Ultrasound-Guided Nerve Block Be A Useful Method Of Anesthesia For Tumor Surgery In The Foot And Ankle
Authors: Lee Gi-Soo , Oh Byung Hak , Kang Chan , Won Yougun , Park Yoo Jung , Jun June Bum
Published: September 2017

Category:

Ankle, Tumor

Introduction/Purpose:

Tumors arising in the foot and ankle are often need surgical treatment. However, there is hesitation about the surgical treatment of anxiety about general anesthesia in some patients. Ultrasound-guided nerve block can be a useful method of anesthesia for tumor surgery in the foot and ankle.This study was performed to compare general anesthesia and ultrasound (US)-guided nerve block for tumor surgery in the foot and ankle. Also, whether US-guided nerve block is a useful method of anesthesia for tumor surgery was investigated.

Methods:

In this prospective, randomized study, 50 patients who underwent tumor surgery between February 2013 and February 2016 were allocated to two groups: general anesthesia (n = 25, or US-guided nerve block (n = 25). All patients completed a questionnaire with three questions 2 weeks after surgery. For the nerve block group, the procedure duration, interval between the procedure and onset of the anesthetic effect, the point of loss of the anesthetic effect, intraoperative, postoperative visual analog scale (VAS) pain score, and discomfort during surgery were assessed.

Results:

There was no patient in which the anesthetic was changed to another method during the operation. VAS pain score of postoperative 1 and 6 h was significantly different between the nerve block group (2.2 ± 1.5 and 3.0 ± 1.8, respectively) and general anesthesia group (5.2 ± 3.9 and 5.4 ± 4.5, respectively) Twenty three US-guided nerve block (92%) and 17 general anesthesia patients (68%) reported that they would prefer the same type of anesthesia if they were to undergo tumor surgery in the foot and ankle again; these differences were significant (P < 0.05). There were no long-term complications, such as neurological deficits or infection, after the procedure in all patients.

Conclusion:

Tumor surgery, such as tumor excision or biopsy, amputation, and other procedures, was performed safely and effectively under US-guided nerve block. These results indicated that US-guided nerve block for tumor surgery is a highly satisfactory and safe procedure without complications and is available for use by any orthopedist.