bluuebunny/crossref_metadata_2025 huggingface dataset:
Alignment of the Hindfoot Following Total Knee Arthroplasty: A Systematic Review
Authors: Azam Mohammad , Butler James J. , Mercer Nathaniel P. , Hurley Eoghan T. , Kennedy John G.
Published: January 2022

Category:

Ankle; Hindfoot

Introduction/Purpose:

The purpose of this systematic review was to evaluate changes in the alignment of the hindfoot following total knee arthroplasty (TKA), subjective clinical outcomes following surgical intervention and to analyze the level of evidence (LOE) and quality of evidence (QoE) of the included studies.

Methods:

MEDLINE, EMBASE, and Cochrane Library databases were systematically reviewed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies reporting changes in the postoperative alignment of the hindfoot following TKA were included. The level and quality of evidence were recorded and assessed.

Results:

Eleven studies with a total of 1142 patients (1358 knees) met the inclusion/exclusion criteria. Six studies were of level of evidence II and 5 studies were of level of evidence III. Patients with preoperative varus knee deformity and valgus hindfoot deformity demonstrated improvement in hindfoot alignment post-TKA. Patients with preoperative varus knee deformity and varus hindfoot deformity demonstrated no improvement in hindfoot alignment following TKA. Twelve different radiographic parameters were used to measure the alignment of the hindfoot across the included studies, with the tibio-calcaneal angle (TCA) most frequently utilized (27.3%).

Conclusion:

This systematic review demonstrated that the hindfoot may display compensatory changes in alignment following total knee arthroplasty in patients with knee osteoarthritis. However, the marked heterogeneity between the included studies and poor quality of evidence limits any meaningful cross-sectional comparisons between studies. Further, well-designed studies are necessary to determine the changes and outcomes of hindfoot alignment following total knee arthroplasty.
Results of Hallux Metatarsophalangeal Joint Arthrodesis with and without Calcaneus Autograft
Authors: Finney Fred T. , Barcel D. , Cohen Bruce E. , Davis W. Hodges , Ellington J. Kent , Irwin Todd A. , Jones Carroll P.
Published: January 2022

Category:

Bunion; Midfoot/Forefoot; Other

Introduction/Purpose:

Hallux rigidus is the most common degenerative arthropathy of the foot. Primary hallux metatarsophalangeal (MTP) joint arthrodesis is the most common surgical treatment for end-stage hallux rigidus and can also be utilized for correction of hallux valgus. Though satisfaction rates following hallux MTP joint arthrodesis are very favorable, nonunion rates have been reported as high as 12%. Many surgeons use orthobiologics and/or autograft to augment arthrodeses about the foot and ankle in an effort to increase union rates. The purpose of this study is to retrospectively compare union rates of hallux MTP joint arthrodesis with and without calcaneus autograft.

Methods:

A query of our institution’s administrative database was performed to identify patients who underwent a primary hallux MTP joint arthrodesis between February 2016 and February 2019. We compared patients who underwent arthrodesis with and without calcaneus autograft. Surgeon preference dictated use of autograft, as some in our group routinely use graft while others do not. Patients 18 years and older who underwent a primary hallux MTP arthrodesis were included. Patients were excluded if they had radiographic evidence of significant bone loss or if allograft or biologic therapies were used. Patient charts and final radiographs were reviewed. The primary outcome was successful union of the hallux MTP joint arthrodesis. Secondary outcomes included preoperative diagnosis, type of surgical fixation and surgical complications. Data was compared using a student T-test.

Results:

There were 336 feet included in the final analysis, and 140 underwent hallux MTP arthrodesis with calcaneus autograft. Mean follow-up time was 14.8 weeks. Among all patients, 89.9% had a successful union. There was no difference in union rates between those who underwent arthrodesis with calcaneus autograft (87.9%) compared to without autograft (91.4%; p = 0.302). Hallux valgus was the preoperative diagnosis in 52.7% of cases followed by hallux rigidus (39.9%). The most common fixation method was a lag screw with a dorsal plate (80.5%). Painful hardware was the next most common complication (8.6%), and smoking and diagnosis of diabetes demonstrated no effect on union rates. In the autograft group, there were no complications related to the calcaneus autograft donor site.

Conclusion:

As orthobiologics and local bone autograft gain popularity in foot and ankle surgery, it is important to report clinical outcomes and establish evidence-based guidelines for use. In this relatively large retrospective comparison, the use of calcaneal graft was noted to be safe (no complications from graft site). However, there was no difference in union rate when comparing hallux MTP arthrodesis with and without calcaneus autograft.
Minimum 5-Year Outcomes of the Lateral Trabecular Metal Ankle Arthroplasty
Authors: Gagné Oliver , Kim Jaeyoung , Caolo Kristin C. , Ellis Scott J. , Demetracopoulos Constantine A. , Deland Jonathan T.
Published: January 2022

Category:

Ankle; Ankle Arthritis

Introduction/Purpose:

The treatment of ankle arthritis has changed significantly with the recent advances in total ankle arthroplasty (TAR). Many different designs of TAR have been used around the world as the biomechanical technology advances and our understanding increases. Most implant system are anterior-based and have a flat cut on the tibial prosthesis. Only one implant, the Trabecular Metal (Zimmer-Biomet, Warsaw, IN), utilizes a lateral approach with a fibular osteotomy to gain access to the tibiotalar joint and a sagittally curved tibial component. Recent publications have described a higher reoperation rate with this implant system. This study aimed to report the 5-year clinical and radiographic outcome as well as the survivorship of the implant.

Methods:

Over a three-year period, two fellowship-trained foot and ankle surgeons used this implant system for patients indicated for TAR. A total of 38 patients were reviewed with an average age of 63.4+-8.6 years-old, BMI of 28.9+-4.6 and the majority (78%) had post-traumatic arthritis. Reoperations and revisions were collected prospectively as part of the local database. Patients participated in surveys preoperatively and at every annual follow-up which included the Foot and Ankle Outcome Score (FAOS). Patients were also evaluated with weightbearing radiographs preoperatively, at the 3 months postoperative and at the 5 year-mark. Those were analyzed by looking at the implant position with validated angles and comparing those over time. Further statistical analysis used paired t-test and Mann-Whitney U test.

Results:

The survivorship for our cohort was 92% at the 5-year mark. Three patients had the implant extracted at 12 and 15 months postoperative. Two of those patients had revisions to stemmed TARs and one had a below-knee amputation. Reoperations otherwise included 4 fibular hardware removal and 5 medial gutter debridement. As seen in Table 1, the FAOS improved significantly for all domains at 5-year compared to preoperative status. The Pain and Symptoms domains improved above than the MCID. The implant positioning both tibial coronal and sagittal as well as talar sagittal did not significantly change between 3 months and 5 years postoperative.

Conclusion:

This study describes the use of a laterally based Trabecular Metal TAR with great survivorship (92%) and clinically significant improvement in patient-reported outcomes. The rate of reoperation is higher due to prominent lateral hardware or poorly visualized medial gutters and revisions had to be performed through an anterior approach. Few other studies report 5-year outcomes from this prosthesis. There is a growing need to present more data from different centers to guide its ongoing clinical use.
2021 IFFAS Award for Excellence Winner: Weightbearing Radiographs Reliably Predict Normal Ankle Congruence in Weber B/SER2 and 4a Fractures: A Prospective Case-Control Study
Authors: Gregersen Martin G. , Molund Marius
Published: January 2022

Category:

Ankle; Trauma

Introduction/Purpose:

In Weber B/SER2-4 ankle fractures assessment with weightbearing radiographs to ascertain stability of the ankle mortise has been advised. However, no previous studies report whether this method leads to preservation of normal ankle congruence in ankles deemed stable. The purpose is to evaluate equivalence of ankle congruence of injured ankles after fracture union versus the uninjured side for stable Weber B/SER2 and partially unstable Weber B/SER4a fracture types.

Methods:

We conducted a prospective, case-control study of 149 patients with an isolated Weber B fracture demonstrating stability on weightbearing radiographs. All participants were treated nonoperatively with a functional orthosis and full weightbearing allowed. Results from gravity stress radiographs classified ankles as SER2 or SER4a fracture types. We defined an equivalence margin in medial clear space difference of 1.0 millimeters. We also evaluated the reliability of obtaining measurements from weightbearing radiographs.

Results:

No difference in medial clear space between the injured and uninjured ankle could be observed after fracture union for stable Weber B/SER2 (mean difference 0.1 millimeters, 95% confidence interval -0.3 to 0.0, P =.056) or partially unstable Weber B/SER4a fracture types (mean difference 0.0 millimeter, (95% confidence interval -0.1 to 0.1, P =.797). No between group differences could be observed (mean difference 0.0 millimeter, 95% confidence interval -0.2 to 0.2, P=.842). These findings were consistent with equivalence as the higher limit of the confidence intervals for the differences were less than the predefined equivalence margin. Estimated 95% confidence intervals for the intraclass correlation coefficients indicated excellent inter- and intraobserver reliability.

Conclusion:

We demonstrated that weightbearing radiographs successfully predict preservation of normal ankle congruence when the weightbearing radiograph is deemed stable. Ankle congruence was equivalent comparing stable Weber B/SER2 and partially unstable Weber B/SER4a fracture types. Excellent reproducibility of the method of obtaining medial clear space measurements was demonstrated.
Automated Volume Measurement of the Syndesmosis Using 3D Weightbearing CT
Authors: Guss Daniel , Lucchese Olivia , Ashkani-Esfahani Soheil , Bhimani Rohan , Waryasz Gregory R. , Kerkhoffs Gino , Lubberts Bart , DiGiovanni Christopher W.
Published: January 2022

Category:

Ankle; Trauma; Other

Introduction/Purpose:

Recent studies have shown that weight-bearing computed tomography (WBCT) that allows 3D volume measurement of the distal syndesmosis while under physiologic load brings about a higher accuracy in detection of syndesmotic instability, especially if subtle. Since the volume measurement method is complex, time-consuming, and has a noticeable interobserver bias, most clinicians might not still be interested in utilizing it in practice. Automatization of this measurement using computer-assisted methods will not only reduce the interobserver bias but also will be faster and more applicable in practice. This study aimed to develop an automated 3D syndesmosis volume measurement tool using image processing methods and compare the speed and the interobserver bias with human interpreters.

Methods:

We included 30 patients with subtle syndesmotic instability who had undergone WBCT and were diagnosed intraoperatively. Thirty individuals with otherwise healthy ankles who had WBCT images were allocated to the control group. The volume measurement up to 5cm proximal to the tibial plafond was considered as the most sensitive and specific method to assess syndesmotic stability based on the literature. An algorithm was developed using MATLAB software that could recognize and calculate the syndesmotic volume using WBCT images. The volume measurement method was used by two orthopaedic surgeons for the same population. The time spent by each surgeon and the algorithm was measured. Finally, the values were compared using the t-test; the interobserver correlation coefficient (ICC) was also calculated. P<0.05 was considered statistically significant.

Results:

The percentage of changes in 3D volume showed a significant difference at 5cm (25.4%; p<0.001), proximal to the tibial plafond. Based on our clinical study, the volume measurement up to 5cm showed a sensitivity of 95.8%, 95%CI:87.8-100, and specificity of 83.3%, 95% CI:68.4-98.2 for detection of syndesmotic instability. The ICC between the clinicians was 75% while using the automated measurement algorithm showed an ICC of 97%. The mean time spent by the clinicians was 268.4+-56.4 and by the algorithm was 2.9+-0.3 seconds (p<0.001, Figure 1).

Conclusion:

Given the fact that 3D volume measurement of the syndesmosis using WBCT is still a complex technique for most clinicians while it is one of the most accurate diagnostic methods based on recent literature, developing a faster and more accurate method for 3D volume measurement of the syndesmosis leads to a more reliable and easier to use the technique to be used in practice.
Impact of Resilience on Long Term Outcomes of Open Brostrom-Gould Repair
Authors: Lameka Megan , Dib Aseel G. , Andrews Nicholas A. , Torrez Timothy , Rallapalle Vyshnavi , Sinha Tanvee , Shah Ashish
Published: January 2022

Category:

Ankle; Midfoot/Forefoot

Introduction/Purpose:

The Brostrom-Gould procedure has become known as the gold standard operative procedure for lateral ankle ligament repair. However, little is known about the factors effecting the intermediate outcomes of the Brostrom- Gould repair as measured by new patient reported outcomes instruments and the impact of resilience on post-operative outcomes. This is the first study investigate the impact of resilience on the outcomes of lateral ligament repair.

Methods:

A retrospective chart review was performed on 173 patients identified using CPT code 27698 who underwent open modified Brostrom Gould lateral ligament repair from Jan 2013 to June 2020. Patient demographics, comorbidities, athletic activities, post op complications as well as co-pathologies commonly seen in CAI were collected. PROMIS Pain Interference v1.1, Physical Function v1.2, and FAAM were collected. Brief Resilience Scale was used to quantify resilience. A linear regression model was constructed to evaluate the independent effect of resilience on each PROMIS and FAAM outcome instrument. Variables were included in the regression model based on an a-priori significance threshold of p<.05 in bivariate analysis.

Results:

Resilience was found to have an independent effect on all PROMIS and FAAM measures when controlling for the effect of confounding variables. Resilience's effect on outcome measures was as follows: PROMIS physical function (Unstandardized β 8.2, 95% CI 3.9 to 12.6), PROMIS Pain Interference (Unstandardized β -4.8, 95% CI -7.9 to -1.7), FAAM Activity of Daily Living Subscale (Unstandardized β 16.6, 95% CI 8.7 to 24.6), and FAAM Sports Subscale (Unstandardized β 28.4, 95% CI 15.9 to 40.9). Preoperative participation in athletic activities also had a positive independent effect on multiple outcomes metrics including: PROMIS Physical Function (Unstandardized β 9.4, 95% CI 2.8 to 16.0), PROMIS Pain Interference (Unstandardized β -5.3, 95% CI - 10.0 to -.582), and FAAM Sports Subscale scores Interference (Unstandardized β 34.4, 95% CI 15.4 to 53.4).

Conclusion:

Resilience and patient participation in athletic activities are independent predictors of improved postoperative functional outcomes as measured by PROMIS and FAAM instruments at intermediate term follow-up. Resilient patients and athletes reported significantly higher physical function and less pain burden postoperatively. Furthermore, preoperative quantification of resilience could enable improved prognostication of patients undergoing lateral ligament repair of the ankle.
Dynamic Syndesmotic Stabilisation and Reinforcement of the Antero-Inferior Tibiofibular Ligament with Internal Brace: Early Results and Clinical Outcome
Authors: Lenz Christopher G. , Shepherd David
Published: January 2022

Category:

Ankle; Arthroscopy; Sports; Trauma

Introduction/Purpose:

Syndesmotic injuries are associated with long recovery times and high morbidity. Systematic reviews show a trend toward better outcomes of dynamic suture buttons compared to screw fixation. Higher rates of malreduction have been reported with screw fixation. The anteroinferior tibiofibular ligament (AITFL) confers the most significant component of translational and rotatory stability. Techniques have developed which reinforce the AITFL. This study aimed to assess results of syndesmotic stabilisation with dynamic stabilisation and reinforcement of the AITFL, with an early mobilisation program.

Methods:

Retrospective case series of 30 patients (mean age 31 years). Syndesmotic instability was confirmed with clinical examination, MRI and weightbearing-CT. In all cases arthroscopic assessment confirmed the instability intraoperatively and anatomic reduction with an AO clamp was achieved under direct vision. Dynamic syndesmotic stabilisation with a single suture button was performed followed by the placement of an Internal Brace over the AITFL. A standardized postoperative rehabilitation protocol was established. Patients were asked to immediately weight bear in a CAM boot for 6 weeks, commence sagittal Range of Motion (ROM) at 2 weeks, cycling at 4 weeks. At 6 weeks patients continued with full ROM and strengthening, running and cutting at 8 weeks and return to sports at 10 weeks. Foot and Ankle Ability Measure (FAAM) scores were collected postoperatively and outcome of acute and chronic injuries were compared.

Results:

The average follow-up was 13 months. The total FAAM score for ADL was 95+-4.9% (range, 83 - 100%) and for sport activities 87+-13.6% (range, 50 - 100%). The rating of mean postoperative function for ADL was 94+-5.5% (range, 80 - 100%) and 90+-13% (range, 35 - 100%) for sportv. The difference between acute and chronic injuries was statistically higher (p<0.05) for daily activities and sport, but the rating of current level of sport activites as well as for daily activites did not show a significant difference (p=0.9296 and p=0.1615, respectively). Twenty-seven patients (90%) rated their overall current level of function as normal or nearly normal.

Conclusion:

This technique aims to directly stabilise the AITFL and the interosseous components of the syndesmosis, and allow early mobilisation and return to sport as early as 10 weeks. Early results show the procedure is safe, with comparable results to the literature. Acute injuries showed better results of the FAAM score than chronic injuries. Long term follow up will address long term outcomes, requirement for removal of devices and how well the Internal brace is tolerated.
Increasing Age and Modifiable Comorbidities are Associated with Short Term Complications after ORIF of Ankle Fractures
Authors: Adams Samuel B. , Danilkowicz Richard , Grimm Nathan L. , Kim Jaewhan , O'Donnell Jeffrey , Allen Nicholas B.
Published: January 2022

Category:

Trauma; Ankle

Introduction/Purpose:

Ankle fractures are common orthopedic injuries with complication rates fixation of up to 40%. Limited evidence exists in the literature regarding complications in the elderly population, and moreover, these studies frequently define elderly arbitrarily at 60-65 years old. The purpose of the present study was to utilize a large, validated database to evaluate whether there is an inflection point of age when postoperative complications after an ankle fracture significantly increase.

Methods:

A retrospective review of all patients in the American College of Surgeons National Surgical Quality Improvement Program database who underwent fixation of an ankle fracture between 2012-2018 was performed. Patients were identified within the database using the Current Procedural Terminology codes. Appropriate statistical analysis was performed with p-value less than 0.05 considered statistically significant.

Results:

A total of 27,633 fractures were including and comprised of 221 posterior malleolar, 1,567 medial malleolar, 8,495 lateral malleolar, 10,175 bimalleolar, and 7,175 trimalleolar. A total of 1,545 complications were encountered (5.6%). There was a statistically significant association between increasing age and complications (OR=1.03; p<0.001). Further analysis shows the largest spike in complications within the age 78+ bracket. There were no overall interaction effects between age and fracture subtype (p=0.223).

Conclusion:

ORIF of ankle fractures is a common orthopedic procedure performed on patients of all ages, with complications ranging in severity. In order to best counsel patients on their individual post-operative risks, large data sets are often necessary to prognosticate. This study found that postoperative complications increase with advanced age. The incidence of complications did not spike for patients around the age of 65, but rather followed an incremental linear pattern with the largest increase in odds ratio occurring at age 78 and above. Complication rate was not associated with specific fracture type based off of ICD codes.
Pain Mapping as a Predictive Model for Diagnosis and Treatment in Foot and Ankle Conditions
Authors: Adukia Vidhi , Hughes Martin , Best Alistair J. , Allen Patricia , Mangwani Jitendra
Published: January 2022

Category:

Other; Ankle; Ankle Arthritis; Bunion; Hindfoot; Lesser Toes; Midfoot/Forefoot

Introduction/Purpose:

With the COVID19 pandemic, virtual consultations are becoming a necessity. Clinicians are having to adapt consultations to determine where patients' symptoms are, and what the appropriate next line of investigation or treatment should be, without the benefit of traditional face-to-face contact. The aim of this project was therefore to use pain mapping in foot and ankle conditions, in order to see if there was a predictive correlation between certain symptomatic areas and the ultimate surgical treatment required by patients.

Methods:

Data was collected prospectively from patients attending foot and ankle clinics from 2014 to 2019, and this was cross- matched with operative data subsequently. Data included patient demographics, co-morbidities, smoking status and previous injuries or surgeries. In a structured questionnaire, patients also marked the regions of the foot and ankle that they thought were the most symptomatic. The foot and ankle was divided into 12 segments for the purpose of analysis.

Results:

A total of 2007 patients completed these questionnaires, from which operative data was available for 407 patients. In the first instance, data was analysed for 122 patients who underwent one of five specific procedures. Pain mapping was found to have a good predictive value for first MTP fusion and bunion surgery (n=20, 46), 1st metatarsal cheilectomy (n=10) and arthroscopic ankle arthrodesis (n=23). The least predictive pain mapping was seen for patients who had a triple arthrodesis (n=23), with those patients presenting with pain more globally in the foot and ankle.

Conclusion:

The results suggest that pain mapping can be used effectively as postal questionnaires, prior to a virtual consultation, as an aid to predict diagnosis and the ultimate treatment required in some specific foot and ankle conditions.
The Generation Game: Has Modern Contemporary Total Ankle Replacement (TAR) Improved Survivorship?
Authors: Ahluwalia Raju S. , St Mart Jean-Pierre , Goh En Lin , Hay Daniel , Pilkington Isobel , Bednarczuk Nadja
Published: January 2022

Category:

Ankle

Introduction/Purpose:

Total ankle replacements (TARs) provide pain relief with preservation of movement and function. The most successful TARs are either 2nd or current 3rd generation in design, whilst 4th generation implants are steadily being introduced. This meta-analysis evaluates the survivorship of 2nd, 3rd and 4th generation ankle replacements used today to determine whether any difference between generations and bearing types exist.

Methods:

A systematic review and meta-analysis of published data from January 2000 to January 2020 was conducted following PRISMA guidelines. Inclusion criteria: English language papers, adult population, >= 20 ankles with a minimum follow up >= 24 months, pre- and post-operative functional scores available. Clinical outcomes of primary TARs were evaluated as well as their associated survivorship. Statistical analyses were undertaken to determine survivorship and complications associated with the second, third and fourth generation implants and the bearing design. Ankle generations were determined from the original studies and confirmed based on literature set definitions. The modified Coleman Methodology Score was used to evaluate the quality of studies.

Results:

A total of 4642 TARs in 4487patients from 51-studies were included. The mean age was 61.9years and mean follow up of 57.8months. The most common indications were post-traumatic-OA (54.5%), primary-OA (25.5%) and inflammatory-arthropathy (15.2%). Relative-risk calculations showed significant reductions in nerve-injury (p < 0.01), post-operative fracture ( p < 0.01), wound complications (p < 0.01), radiolucencies ( p < 0.01), or heterotopic bone formation (p < 0.01), aseptic loosening (p < 0.01) for later generations. Sensitivity analysis performed for the withdrawal of 2 prostheses showed 2yr survivorship for 2nd, 3rd and 4th generation TARs was 95.3%, 97.9% and 98.9% (p < 0.05). Third-generation TARs had better 10-yr survivorship compared to 2nd generation (83.50% vs. 70.76%) (p < 0.01). Bearing design had little influence on survivorship.

Conclusion:

In the real world subsequent generations of modern contemporary TAR demonstrate lower rates of complications and improved survivorship independent of bearing design, without reaching designer series levels. Population changes have meant a reduction in mean age at implementation and the commonest pathology for a TAR has become post traumatic OA without a observed detrimental affect in outcomes. Even so, superior short-term survivorship of fourth generation implants is promising for the future of modern TAR surgery.
Cost Analysis and Utilization of Weight Bearing CT
Authors: Alexander Nathaniel B. , Bettin Clayton C. , Sarfani Shumaila , Strickland Carson D. , Richardson David R. , Murphy G. Andrew , Grear Benjamin J.
Published: January 2022

Category:

Other

Introduction/Purpose:

Weightbearing Computed Tomography (WB CT) is becoming a valuable tool in the evaluation and understanding of foot and ankle pathology. With this, more practices may be interested in acquiring WB CT scanners and understanding cost effectiveness of acquisition. To date there are currently no US based reports of cost analysis of WB CT scanners. Our study is a cost analysis of WB CT at tertiary referral physician owned practice.

Methods:

Data was collected for all patients who underwent imaging utilizing a weight bearing CT scanner at our institution from the date of acquisition in 2016. For ease of analysis and applicability of information across orthopedic practices, Medicare reimbursement was used as a uniform estimation of reimbursement across all insurances at a rate of $163.50 per scan. We then compared the number of scans obtained per month to total costs related to acquiring and maintaining the WB CT machine. Secondary variables collected included patient demographic information, pathology location (forefoot, midfoot, hindfoot), and utilization of the device by subspecialty.

Results:

A WB CT scanner was acquired by a private group in 2016. A proforma analysis demonstrated $179,000 to acquire the machine, $30,000 for extended warranty, $995 for additional licenses. Between August 2016 and February 2021, 1702 unilateral studies and 100 bilateral studies were performed. Patients ranged in age from 6 to 92. Average age was 45 years with 45.9% male and 54.1% female. Forty-one staff utilized the CT scanner from various subspecialties with 5 Foot and Ankle (F&A) surgeons ordering 80% of scans. When dividing total costs by number of months since acquisition the monthly cost of the device is $3,318 which requires 20 scans per month when using Medicare reimbursement rates. Over a 55 month the average number of scans per month is 34. When dividing the cost of acquisition by reimbursement per scan, the breakeven point was 1,284 scans which occurred at approximately 3 years.

Conclusion:

As WB CT scans become a valuable tool for the analysis of foot and ankle pathology, groups may be interested in understanding the financial implications of such an investment. Our study is the only cost analysis based in the United States of WB CT. We found that WB CT is a cost-effective tool that can be used to evaluate a number or pathologies in the foot and ankle.
Ten-Year Outcomes of MobilityTM Total Ankle Replacement Confirms Radiological Loosening is Not Conclusive or Reliable for Long Term Survival Analysis
Authors: Alkhreisat Mohammad A. , Ramaskandhan Jayasree Ramas , Bennett Adam P. , Smith Karen , Siddique Malik S.
Published: January 2022

Category:

Ankle; Ankle Arthritis

Introduction/Purpose:

Different designs of Ankle replacement are being performed nowadays, long-term outcome data is the better way to understand these implants behaviour and survival. We compared the differences in demographic data, clinical, Radiological, and patient-reported outcomes among patients who underwent total ankle replacement performed with use of the uncemented stemmed mobile bearing (MOBILITY) Total Ankle System with 10 year follow up.

Methods:

We analysed 156 (15 bilateral ankles (3 non-mobility) Mobility TAR (of which 41, 45, 22 for OA, PTOA, Inflammatory arthritis respectively). Mean age 61.7 (SD 11.4) (Range 33-90). 70 Ankles had 10 years of follow up, 115 had 5 years follow up,. 96 were males, with 30 patients deceased before 10 years follow up covering 33 ankles. All from our local registry looking at the patient's demographic data, and patient-reported outcomes as measured with use of WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index), the Foot and Ankle Outcome Score (FAOS), the 36-item Short-Form (SF-36) Health Survey, clinical and radiological outcomes and patient-satisfaction scores, collected preoperatively and at 1,3,5 and 10 years postoperatively.

Results:

Of the 156 ankles18 had wound complications after surgery two only needed surgical debridement. 5 CRPS,16 stress fractures 2 only requiring surgical fixation,11 had subsequent STJ fusion.77 had no signs of radiolucency. The rest had some degree of radiolucency on x-ray (55% on the tibia side) only 11 where symptomatic to require further surgery (6 revised to another TAR, 2 fused, and3 required bone grafting). 11 needed osteotomies after surgery. Aseptic loosening and infection are the least common complications requiring revision. There was significant improvement in WOMAC for pain (35.9 to 67.9), function (40.6 to 66.9) and stiffness (39.4 to 62.5) from pre-op to 1 year (p<0.05), this was maintained for 10 years. Although improvement noted in the composite physical component of SF=36 (28.3 to 34.5) there was no significant increase for composite mental component score. 77.5% reported satisfaction from pain relief,72.4% with return to ADL, 40% were dissatisfied with return to recreational activities and15.5% reported dissatisfaction with overall results of surgery. Mobility TAR shown about 86% survival in our 10 years cohort.

Conclusion:

With improved PROMS at 1,3,5,10 years showing Patient satisfaction score at 10 years indicates that uncemented mobile bearing implants have good long-term results, osteolysis and aseptic loosening as the least common cause of revision. It is pertinent that reporting of radiological loosening in an uncemented ankle is not conclusive or reliable for long term survival analysis.
Assessment of Ankle Fractures using Deep Learning Algorithms and Convolutional Neural Network
Authors: Ashkani-Esfahani Soheil , Mojahed-Yazdi Reza , Bhimani Rohan , Kerkhoffs Gino , Guss Daniel , DiGiovanni Christopher W. , Lubberts Bart
Published: January 2022

Category:

Ankle; Trauma

Introduction/Purpose:

Early and accurate detection of ankle fractures is crucial for reducing future complications. Radiographs are the most abundant imaging techniques for assessing fractures. We believe deep learning (DL) methods, through adequately trained deep convolutional neural networks (DCNNs), can assess radiographic images fast and accurate without human intervention. In this study, we aimed to assess the performance of two different DCNNs in detecting ankle fractures using radiographs compared to the ground truth.

Methods:

In this retrospective study, our DCNNs were trained using radiographs obtained from 1050 patients with ankle fracture and the same number of individuals with otherwise healthy ankles. Inception V3 and Renet50 pre-trained models were used in our algorithms. Danis-Weber classification method was used. Out of 1050, 72 individuals were labeled as occult fractures as they were not detected in the primary radiographic assessment. Using single-view radiographs was compared with 3-views (anteroposterior, mortise, lateral) for training the DCNNs.

Results:

Our DCNNs showed a better performance using 3-views images versus single-view based on greater values for accuracy, F-score, and area under the curve (AUC). The sensitivity and specificity in detection of ankle fractures using 3-views were 97.5% and 93.9% using Resnet50 compared to 98.7% and 98.6 using inception V3, respectively. Resnet50 missed 3 occult fractures while Inception V3 missed only one case. In cases that detected the fracture, the saliency map showed the location of the fracture ( Figure 1 ).

Conclusion:

The performance of our DCNNs showed a promising potential that can be considered in developing the currently used image interpretation programs or as a separate assistant to the clinicians to detect ankle fractures faster and more precisely.
Intramedullary Nailing vs Plating of the Fibula for Ankle Fractures in the Young Active Patient
Authors: Bastias Gonzalo F. , Mikenberg Natalio R. Cuchacovich , Diaz Felipe G. , Gutierrez Paulina , Munoz Gerardo , Melo Rodrigo , Jofre Magdalena I. , Filippi Jorge
Published: January 2022

Category:

Ankle; Trauma

Introduction/Purpose:

The use of fibular nailing (FN) for fixation of lateral malleolar fractures has been rising in recent years. Currently, it has been validated as an effective minimally invasive approach to ankle fractures specially in patients with high risk of wound dehiscence, diabetics and elderly low-demand patients. While most of the studies comparing the use of a fibula nail versus plating (PL) are carried out in this population at risk, the use of FN in younger patients with higher functional demands has been hardly studied. The aim of this study is to compare the functional and quality of life outcomes of patients treated with FN and PL in an active population.

Methods:

We performed an IRB-approved retrospective study including ankle fractures treated in our hospital from January 2017 to February 2020, with a minimum followup of one year. We included only patients between 18 and 55 years old treated by five fellowship-trained foot and ankle surgeons and divided into two groups according to the method of fixation of the fibula: intramedullary nailing (FN) or plating (PL). Demographics, medical comorbidities, type of fracture, reoperations and complications were collected. Functional and clinical evaluation included the Lower Extremity Functional Score (LEFS) and Short form 12 (SF 12) were obtained at an average of 28 months follow-up (range 14-50).

Results:

Eighty-five patients were included in this study with a mean age of 36.9 years old (range 16-55). The FN group was conformed by 31 patients (18 men) while the PL group consisted of 54 patients (32 men). Both groups were comparable in terms of age, sex, type of fracture, open fractures, number of malleoli compromised (P>0.05). Union was achieved in all patients. The complication rate was 3.2% (1 patient) in the FN group versus 5,5% (3 patients) in the PL group (p=0.66). Two patients (6.5%) in the FN group and 7 patients (13%) in the PL group required hardware removal (p=0.36). There were no significant differences in SF-12 physical component (p=0.30), SF-12 Mental component (p=0.52) and LEFS Score (p=0.88).

Conclusion:

In this comparative study, there were no differences between the FN and PL groups for fixation of the fibula in terms of functional results and quality of life at an average of 28 months follow-up. Complications and hardware removal rates had no statistical differences between both groups. This is the first report on the literature comparing both fixation strategies on an active high-demand population.
Ankle Fusion Outcomes Utilizing Anterior Ankle Plating Techniques: A Systematic Review
Authors: Berlet Gregory C. , Prissel Mark A. , Zulauf Emily E. , Malloy McCoy Antonio M.
Published: January 2022

Category:

Ankle; Ankle

Introduction/Purpose:

Ankle arthrodesis is a time-tested surgical treatment for end-stage ankle arthritis. Fixation constructs continue to evolve with recent advancements in anterior ankle plating. A systematic review of anterior approach ankle arthrodesis using anterior plating was performed to analyze outcomes such as time to weight bearing, union rate, and complications.

Methods:

A systematic literature search was performed following Preferred Reporting Items for Systematic Reviews and Meta- Analyses (PRISMA) guidelines was performed. Inclusion criteria were as follows: 1) prospective or retrospective comparative study or consecutive case series reporting clinical outcomes following ankle arthrodesis; 2) surgeon technique includes anterior incisional approach with anterior plating construct; 3) minimum 3 months follow-up; and 4) reported outcomes including time to weight bearing, union or nonunion rate, complications, and patient population characteristics including age and comorbidities. Thirteen citations met inclusion criteria. Studies were organized into three groups based on similar time to weightbearing protocols.

Results:

Mean time to weightbearing was as follows: Group A. 0.6 weeks, Group B. 6 weeks, and Group C. 9 weeks with fusion rates of 95.2%, 95.4%, and 96.6%, respectively. The average time to weightbearing post-operation across all groups was 4.6 weeks with a mean union rate of 95.3% (82 to 100%).

Conclusion:

Wound healing complications and infection rates did not increase with earlier weight bearing guidelines. This systemic review revealed comparable fusion rates across different weight bearing regimens following anterior plate fixation for ankle arthrodesis, supporting re-evaluation of historically accepted weightbearing protocols.
The Medial Gastrocnemius Release: A Safe and Effective Alternative for Treatment of Isolated Gastrocnemius Contracture
Authors: Bull Patrick E. , Malloy McCoy Antonio M. , Thompson Mitchell , McGann Maria R. , Berlet Gregory C.
Published: January 2022

Category:

Basic Sciences/Biologics

Introduction/Purpose:

Gastrocnemius recession is a popular procedure utilized to treat a myriad of lower extremitychronic conditions related to isolated gastrocnemius contracture (IGC). Recent anatomical research detailing the variable relationship between the distal gastrocnemius and soleus tendons has raised important questions regarding the safety of some traditional recession procedures. Alternative gastrocnemius recession strategies may offer comparable clinical results while avoiding the surgical risk related to conjoint tendon anatomical variability.

Methods:

Ten matched pairs of above-knee fresh frozen cadavers were randomized to receive either a medial gastrocnemius recession (MGR) procedure or a gastrocnemius intramuscular recession 'Baumann' procedure. Postoperative dorsiflexion improvement was measured and then compared between groups. Detailed post-operative surgical dissections were performed on all specimens to assess structures at risk, conjoint tendon morphology, and anatomical symmetry.

Results:

MGR and GIAR procedures were equally effective at producing significant increases in passive ankle dorsiflexion. No sural nerve injuries were observed. 35% of specimens showed direct muscular fusion of at least a portion of the distal gastrocnemius muscular tissue to the adjacent soleus, with sections of no distal transactable gastrocnemius tendon present.

Conclusion:

The MGR produced comparable results to the Baumann/GIAR in a cadaver model. We feel that the MGR is an attractive alternative to traditional gastrocnemius recession techniques due to the simple approach, the region's predictable anatomy, its low risk to surrounding vital structures, and its early evidence of effectiveness. We also concluded that the conjoint tendon anatomy is highly variable and that surgeons must account for this unpredictability when surgically treating IGC. We predict that the biggest risk associated with conjoint tendon region recession procedures is inadvertent soleus transection and subsequent over lengthening related plantar flexion weakness.
Benefits of Ankle Arthroscopic Debridement in Acute and Subacute in Ankle Fractures
Authors: Ceccarini Paolo , Marzano Fabrizio , di Giacomo Lorenzo , Rinonapoli Giuseppe , Caraffa Auro
Published: January 2022

Category:

Ankle; Arthroscopy; Trauma

Introduction/Purpose:

The purpose of this study was to evaluate the benefits of ankle arthroscopy at the time of ORIF or after six months in patients with residual symptoms. The hypothesis was that in patients treated arthroscopically at the time of ORIF, there were faster and better clinical results than those treated after or untreated with arthroscopy.

Methods:

In this retrospective study, we compared three homogeneous groups of selected patients with specific inclusion criteria (144in total, mean age 38.2 years). They have been surgically treated for an ankle fracture (bimalleolar or trimalleolar without frank syndesmotic injuries) with open technique (ORIF) or arthroscopic ORIF (AORIF), between 2016 and 2019. The AO classification system was used for each patient. The clinical assessment was based on the Foot and Ankle Outcome Score (FAOS).

Results:

At the final follow-up (mean 36 months), both patients treated with ankle arthroscopic debridement at the time of ORIF and patients treated with arthroscopic debridement after ORIF showed a significant improvement of the FAOS, which reported84 and 85 respectively at final follow-up.

Conclusion:

Through direct visualization of intra-articular structures, ankle arthroscopy can offer an essential option for patients both in acute and in sequelae after an ankle fracture. More studies are needed to understand the real effectiveness of the procedure, especially in acute at the same time of osteosynthesis.
Corticosteroid Injection for Morton’s Interdigital Neuroma: A Systematic Review
Authors: Choi Jun Young , Kim Min Jin , Suh Jin Soo
Published: January 2022

Category:

Lesser Toes; Midfoot/Forefoot

Introduction/Purpose:

This review aimed to evaluate the effects of corticosteroid injections for Morton's neuroma using an algorithmic approach to assess the methodological quality of reported studies using a structured critical framework.

Methods:

Several electronic databases were searched for articles published until April 2020 that evaluated the outcomes of corticosteroid injections in patients diagnosed with Morton's neuroma. Data searches, extraction, analysis, and quality assessments were performed according to the PRISMA guideline, and the clinical outcomes were evaluated using various outcome measures.

Results:

With 3-12 months of follow-up, corticosteroid injections provided a satisfactory outcome according to Johnson satisfaction scores without two studies. Visual analogue scale scores showed maximal pain reduction between 1 week and 3 months post-injection. We found that 140 subjects out of 469 (29.85%) eventually underwent surgery after receiving corticosteroid injections due to persistent pain.

Conclusion:

Corticosteroid injections showed a satisfactory clinical outcome in patients with Morton's interdigital neuroma in spite of almost 30% of included subjects eventually underwent operative treatment. Our recommendation for the future study includes using more objective outcome parameters, such as foot and ankle outcome scores or foot and ankle ability measures. Moreover, studies about the safety and effectiveness of multiple injections at the same site are highly necessary.
Retrospective Study Analyzing Trends in Antibiotic Use in Patients with Osteomyelitis of the Ankle and Foot
Authors: Chokshi Shivan N. , Efejuku Tsola , Jupiter Daniel , Chen Jie , Panchbhavi Vinod K.
Published: January 2022

Category:

Ankle; Hindfoot; Midfoot/Forefoot

Introduction/Purpose:

Antibiotic resistance has quickly become one of the most pressing current public health challenges. Many studies have analyzed general prescription trends, but little information exists about how antibiotic therapy is utilized in orthopedic practice- particularly in patients with Osteomyelitis of the Ankle and Foot. Thus, a retrospective analysis was performed using EMR data to understand temporal tends in antibiotic use, as well as the impact of patient-specific factors on antibiotic use.

Methods:

Patients with Osteomyelitis of the Ankle and Foot who were given antibiotics within 12 weeks of their diagnosis were identified in the EMR database using ICD 10 codes (M86.17, M86.67, M86.8X7, M86.171, M86.172, M86.27, M86.679, M86.279, M86.671, M86.672, M86.07, M86.271, M86.37) for foot and ankle Osteomyelitis and the VA Drug Classification Code (AM000) for antibiotics. We then stratified these patients by age (0-9, 10-19, 20-29, 30-39, 40-49, 50-59, 60-69,70-79, 80-89, 90-99), gender (male, female), and year by decade (2001, 2010, 2020). In addition, pre-disposing risk factors of Osteomyelitis, such as Diabetes, Hypertension, and Chronic Ischemic Heart Disease, were analyzed for association with antibiotic use.

Results:

Our search identified 85,767 patients, of whom 50,043 (58.35%) received antibiotics within 12 weeks of Osteomyelitis diagnosis. Overall, Males (60.01%) were slightly more likely than Females (54.88%) to use antibiotics. Stratification by age revealed a skewed distribution with the highest incidence of antibiotic use seen in 50-59 year-olds (61.93%). This was more than double the incidence of antibiotic use seen among 20-29 year-olds (30.63%). Additionally, we discovered notable increases in antibiotic usage over time. The most substantial increases occurred from 2001 to 2010 (14.08% to 33.71%, respectively) and 2010 to 2020 (33.71% to 60.51%, respectively). Lastly, patients with pre-existing co-morbidities were found to have a higher usage of antibiotics, when compared to patients without the co-morbidity. Specifically, prior Hypertension increased use by 11.73%, followed by Chronic Ischemic Heart Disease (10.50% increase) and Diabetes (8.40% increase). The above differences were found to be statistically significant at a p-value of <.0001.

Conclusion:

This analysis provides insight into present and past antibiotic usage in patients with Foot and Ankle Osteomyelitis. Overall, patients aged 50-59, males, and with Chronic Ischemic Heart Disease are the most likely to take antibiotics within 12 weeks of their diagnosis. This is all against the background of rising antibiotic use, with notable increases since 2001. The data necessitates a deeper look into antibiotic use in patients with foot and ankle injuries as a whole.