bluuebunny/crossref_metadata_2025 huggingface dataset:
Scarf and Weil osteotomy for symptomatic hallux valgus does not fully remove second toe residual metatarsalgia
Authors: Loh Bryan , Koo Kevin , Liow Ming Han Lincoln , Lim Winston Shang Rong , Ng Chong Zheng , Rikhraj Inderjeet
Published: September 2018

Category:

Bunion

Introduction/Purpose:

Patients with hallux valgus (HV) often experience concurrent second toe metatarsalgia due to altered forefoot biomechanics. Additional second toe Weil osteotomy has been performed to reduce transfer metatarsalgia as some studies have highlighted the presence of second toe pain after isolated HV correction. 1, 2 There is a paucity of literature evaluating residual second toe pain after these procedures . We hypothesize that combined Scarf/Weil osteotomy will result in less residual second toe pain while achieving good functioning outcome. The aim of this study was to evaluate the presence of second toe pain after isolated scarf osteotomy versus combined Scarf/Weil osteotomy.

Methods:

Between January 2007 and June 2012, 439 patients underwent a scarf osteotomy for symptomatic hallux valgus at a tertiary hospital. Patients who underwent isolated scarf osteotomy were matched 1:1 to patients who had both Scarf and second toe Weil osteotomy. The following functional outcome scores were prospectively collected preoperatively and postoperatively at 6 and 24 months: American Orthopaedic Foot and Ankle Society (AOFAS) Hallux Metatarsophalangeal-Interphalangeal (MTP-IP) Scale, Visual Analog Scale (VAS), SF36-Physical Component Score (PCS) and Mental Component Score (MCS). Radiological outcomes such as the Hallux Valgus Angle (HVA) and Intermetatarsal Angle (IMA) were measured. Statistical analysis was performed using SPSS® 20.0 and significance was defined as a p-value = 0.05. The Student’s unpaired t-test was used to compare the radiological and functional outcomes between the two groups of patients, while the paired t-test was used to analyze improvement in pre- and postoperative outcomes within each group.

Results:

94.4% of the patients were female and no difference in BMI. In the Scarf/Weil group, the HVA and IMA improved by 21.2 ± 10.2 and 8.2 ± 4.7 degrees respectively (both P<0.001). At 2 years, the AOFAS-hallux score improved by 26.6 ± 20.9 (p=0.034), AOFAS-second toe by 29.3 ± 20.9, VAS-hallux by 3.1 ± 3.4 (p<0.001), VAS-second toe by 3.6 ± 3.2 (p<0.001). In the Scarf group, the HVA and IMA improved by 17.1 ± 8.0 and 5.8 ± 4.3 degrees respectively (both p<0.001). At 2 years, the AOFAS-hallux score improved by 32.2 ± 21.2 (p=0.034), AOFAS-second toe by 13.0 ± 16.3 (p <0.001), VAS-hallux by 4.4 ± 3.3 (p<0.001), VAS-second toe by 1.2 ± 2.4 (p<0.001).

Conclusion:

A significant finding is that at 6 months and 2 years, the VAS-2nd toe score in the isolated Scarf group was 1 ± 0 point lower than the other group (p<0.001). All other functional outcome scores were comparable between the two groups at 6 months. Our findings suggest that shortening second toe Weil osteotomy for large HV deformity may not fully resolve second toe metatarsalgia in the short-term, providing useful information for preoperative counselling.
Prevalence of isolated gastrocnemius tightness in patients with foot and ankle pathology – a population based study
Authors: Malhotra Karan , Chan Oliver , Cullen Nicholas , Welck Matthew , Goldberg Andrew , Singh Dishan
Published: September 2018

Category:

Other

Introduction/Purpose:

Gastrocnemius tightness (GT) is thought to predispose patients to multiple musculoskeletal pathologies including back pain, plantar fasciitis, and metatarsalgia. It is thought to be especially prevalent in patients with foot and ankle pathology (FAP) and consequently there is an emerging trend to perform lengthening / release procedures in this patient group. However, it is not clear what proportion of the normal population has GT and how this differs in patients with FAP. We set out to investigate what the incidence and degree of GT in the foot and ankle population is compared to the normal population.

Methods:

This was a prospective study comparing GT in a cohort of patients with FAP with GT in controls matched for age, gender, and ethnicity. The control group consisted of healthy adult volunteers and the FAP group consisted of patients presenting to our Foot & Ankle unit. Patients with previous surgery, tendoachilles tightness, or ankle arthritis were excluded. GT was measured using a digital inclinometer and the lunge test. It was calculated as the difference between maximal ankle dorsiflexion with the knee extended and with the knee flexed. Data on the control group was collected first and a power calculation suggested a FAP cohort size of 91 feet was required to detect a 2° difference in GT (a= 0.05, ß = 0.05, Ratio 3:1).

Results:

After case-matching 97 FAP cases were paired with 291 controls for analysis. Mean GT was 8.0° ±5.7° (range: 0-21°) in FAP patients versus 6.0° ±3.5° (range: 0-16°) in controls (p<0.001). Regression analysis demonstrated demographics including BMI and activity level were not significant determinants of GT in the FAP group (r=0.141, p=0.599). Subgroup analysis of the FAP group revealed a mean GT of 10.3° ±6.0° in patients with forefoot pathology (FoP) versus 6.9° ±5.3° in the other FAP patients (NFoP) (p=0.008). When comparing the NFoP group to the controls, there was no difference in GT (p=0.188). In total 21 FAP patients (21.6%) and 12 FoP patients (37.5%) had GT greater than 2 standard deviations of the control group (Figure 1).

Conclusion:

This population based study demonstrates increased GT in the FAP population versus the normal population; however, in patients without forefoot pathology, this difference may not be clinically relevant. Over a third of patients with forefoot pathology have GT which is greater than the normal population range. We conclude that not all patients with foot and ankle pathology have inherently increased GT, compared with the normal population, but it is reasonably common in patients with forefoot pathology. Further work is required to define what degree of GT may be considered significant, to determine which patients will benefit from surgical treatment.
Anatomical Feasibility Study of Flexor Hallucis Longus Transfer in Treatment of Achilles Tendon and Posterior Ankle Arthroscopy
Authors: Mao Haijiao
Published: September 2018

Category:

Hindfoot

Introduction/Purpose:

The aim of this study was to evaluate the occurrence of anatomical variations of the musculotendinous junction of the flexor hallucis longus (FHL) muscle, the relationship between FHL tendon or muscle and the tibial neurovascular bundle at the level of the posterior ankle joint in human cadavers.

Methods:

Seventy embalmed feet from 20 male and 15female cadavers, the cadavers’ mean age was 65.4 (range from 14 to 82) years, were dissected and anatomically classified to observe FHL muscle morphology define the relationship between FHL tendon or muscle and the tibial neurovascular bundle . The distance between the musculotendinous junction and thehe relationship between FHL tendon or muscle and the tibial neurovascular bundle was determined.

Results:

The three morphology types of FHL muscle were identified: a long lateral and shorter medial muscle belly, which was observed in 63 specimens (90%).; equal length medial and lateral muscle bellies, this variant was only observed in 5 specimens (7.1%); a lateral and no medial muscle belly, which was observed in 2 specimens (2.9%). No statistically significant difference was observed according to gender or side (p > 0.05). Two patterns were identified and described between FHL tendon or muscle and the tibial neurovascular bundle. Pattern 1, the distance between the neurovascular bundle and FHL tendon was 3.46 mm (range, 2.34 to 8.84, SD = 2.12) which was observed in 66 specimens (94.3%); Pattern 2, there was no distance which was observed in 4 specimens (5.7%).

Conclusion:

Knowing FHL muscle morphology variations provide new important insights into secure planning and execution of a FHL transfer for Achilles tendon defect as well as for the interpretation of ultrasound and magnetic resonance images. During posterior arthroscopic, posteriormedial portal may be introduced into the posterior aspect of the ankle without gross injury to the tibial neurovascular structures.
Ultrasound Evaluation of Peroneal Tendon Location Within the Fibular Groove
Authors: Martin Kevin , Wake Jeffrey
Published: September 2018

Category:

Sports

Introduction/Purpose:

The use of MRI in diagnosing peroneal tendon dysfunction can be difficult due to the anatomic orientation of the tendons and their relationship to the posterior fibula. MRI is also limited in its roll in diagnosing dislocation or intrasubstance subluxation due to the static nature of the examination. Due to these limitations Ultrasound has become increasingly more common. The purpose of this study was to identify the location of the peroneal tendons in relationship to the fibular groove during a dynamic examination in an asymptomatic population of elite United States Military Service members.

Methods:

We conducted a prospective cohort study composed of 41 active duty United States Army Rangers. Each subject was examined bilaterally. Subjects were placed in a lateral recombinant position and the ankle placed in a resting neutral position to visualize the tendon in a retromalleolar short-axis view. Next, maximum active ankle eversion followed by gravity inversion while the ultrasound probe was maintained in its original position. The distance from the fibrous lateral ridge of the retromalleolar groove to the anterior aspect of the peroneal brevis was measured in the short-axis in all three positions (Neutral, Eversion and Inversion).

Results:

The mean sagittal distance was 0.48 mm. No subjects demonstrated greater than 1 mm difference between the three positions, no dislocations were identified. The side to side difference and dominant vs non-dominant differences were not statically significant.

Conclusion:

The current study demonstrates the distance between the peroneal brevis and the lateral fibular ridge is consistent throughout extremes of motion in an asymptomatic population. These results help further the understanding of the peroneal tendons while performing a dynamic exam. Our findings also establish side-to-side consistency prompting a bilateral examination to help identify abnormal pathology. The current study also offers clinicians another means of evaluating reported peroneal tendon subluxation prior to MRI or further subspecialty consultation.
Hallux Valgus
Authors: Mierke Alex , Morris Stephen , Epperly Scott , Kidd Deon , Patton Daniel
Published: September 2018

Category:

Bunion

Introduction/Purpose:

Abnormal motion of the first tarsometatarsal (TMT) joint disrupts the anatomic alignment of the metatarsal head, sesamoid complex and proximal first phalanx. This anatomic disruption combined with the deforming forces of the extensor hallucis longus, adductor tendons, and extensor hallucis brevis result in a hallux valgus deformity. First TMT arthrodesis or the Lapidus procedure has been described as treatment for moderate to severe hallux valgus deformities by correcting hypermobility and restoring anatomic alignment of the first ray. The aim of this study was to evaluate the safety of a percutaneous approach to the Lapidus procedure and its relation to anatomic structures.

Methods:

A percutaneous, modified Lapidus procedure was performed on 19 embalmed cadaveric feet under fluoroscopic guidance. The specimens were then dissected to identify the extensor hallucis longus (EHL), extensor hallucis brevis (EHB), tibialis anterior (TA), median branch of the superficial peroneal nerve (MBSPN), intermediate branch of the superficial peroneal nerve (IBSPN), deep peroneal neurovascular bundle (DPNVB) and saphenous vein (SV). The structures were localized with reference to percutaneous burr and screw placement during the procedure.

Results:

The tibialis anterior and intermediate branch of the superficial peroneal nerve were a mean of 3.75 millimeters (mm) and 5.08 mm from the closest burr or screw placement. The extensor hallucis longus and extensor hallucis brevis were at greatest risk under the new approach with mean distances of .92 to 4.08 mm to nearby instrumentation. The extensor hallucis longus or extensor hallucis brevis were either directly pierced or <2 mm from instrumentation on 26 occasions. A terminal branch of the saphenous vein was also either pierced or within 2 mm of instrumentation on 4 occasions. The deep peroneal neurovascular bundle and median branch of superficial peroneal nerve were relatively safe, coming within 2 mm of percutaneous burr or screw placement on only 2 occasions each.

Conclusion:

The minimally invasive percutaneous Lapidus arthrodesis provides a safe alternative to the traditional, open approach for patients with moderate to severe hallux valgus deformities. This may be a beneficial alternative to conventional open Lapidus procedures by minimizing soft tissue dissection. Further clinical studies must be performed to compare deformity correction, fusion rate, and complications with the modified percutaneous Lapidus procedure.
Outcome of Charcot’s arthropathy of the midfoot treated by internal fixation as per PROMIS scoring system
Authors: Moonot Pradeep , Bal Arun , Sharma Gaurav , Tadepalli Kalyan
Published: September 2018

Category:

Midfoot/Forefoot

Introduction/Purpose:

Charcot’s neuropathy is a chronic and destructive condition primarily affecting the joints of foot and ankle which can lead to severe disability sometimes even requiring amputation. Midfoot charcot’s can alter the normal biomechanics of the foot leading to point loading and ulcer formation. Different modalities with variable results have been proposed for this devastating condition. Patient reported outcome measurement information system (PROMIS) is a patient, fast and reliable validated tool with different clinical domains to assess the post-operative outcome measures in various aspects of foot and ankle surgery. The aim of the present study was to assess the Pre and post-operative PROMIS scoring of three parameters (Physical function, fatigue and social role) in diabetic patients with Charcot’s neuropathy affecting the midfoot.

Methods:

A prospective study was conducted at a tertiary care diabetic centre on 13 patients with Charcot’s midfoot treated with internal fixation by a single surgeon. Out of 13 patients who met the inclusion criteria, 3 patients had ulcer over the plantar aspect of the foot which was initially treated with contact cast for 6 weeks following which 2 patients were operated using internal fixation and 1 was excluded. Pre and post-operative PROMIS scores were recorded and the final outcomes were measured. The midfoot was fixed with either locking plates or long cannulated screws.

Results:

The mean age of the patients were 53.2±9.6 years with a mean duration of diabetes since 7.3 years. The average hospital stay was 3.7±1.5 days. Union was achieved in 13.4±2.7 weeks. The mean RAW scores for physical function, fatigue and social role measured pre-operatively were 8.33±2.53, 16.83±2.44 and 16.75±2.80 which later improved post-operatively to 16.75±2.63, 6.91±2.31 and 6.16±1.58 respectively. There was an improvement between the pre and post-operative PROMIS scores which was statistically significant (P<0.001). Two (16.66%) cases had deep infection which required screw removal 8 months from the index surgery. However, the final outcome was a stable and plantigrade foot. One (8.3%) case had superficial infection which responded well to antibiotics. No patient required amputation in the present study.

Conclusion:

PROMIS scoring is a patient based scoring system which can assess the prognosis and apply the same clinically. Midfoot charcot’s neuroarthropathy can we managed well by internal fixation (locking plates &/or screws) providing adequate stability and plantigrade foot
Evaluation of articular cartilage injury using computed tomography with axial traction in ankle joint
Authors: Nakasa Tomoyuki , Ikuta Yasunari , Yoshikawa Masahiro , Tsuyuguchi Yusuke , Ota Yuki , Kanemitsu Munekazu , Adachi Nobuo
Published: September 2018

Category:

Ankle

Introduction/Purpose:

Although chondral or osteochondral injuries are usually assessed by MRI, its accuracy is reportedly low because of the relatively thin cartilage layer and its close apposition to the cartilage talus and tibial plafond. The subchondral bone plays a role in cartilage metabolism, therefore the evaluation of subchondral bone is crucial for cartilage treatment. A method which enables the simultaneous evaluation of cartilage and subchondral bone is useful for the treatment of cartilage injury. The purpose of this study was to assess the feasibility of CT imaging with axial traction for the diagnosis of articular cartilage injuries.

Methods:

Chondral lesion in 18 ankles of 17 patients were evaluated. These 18 ankles consisted of 11 ankles of osteochondral lesion of the talar dome (OLT), 5 ankles of osteoarthritis of ankle joints and 2 ankles of anterior impingement syndrome. Twelve males and 5 women were included, with a mean age of 33.7 years (range, 15 -70 years). An ankle distractor foot strap was placed on the ankle with 30 degrees flexion of the knee joint, and a traction force of 80 N was applied during CT scanning. Gray scale CT images were allocated colors to make it easier to evaluate the cartilage layer. The international Cartilage Repair Society (ICRS) grades on CT were compared with those in arthroscopic findings.

Results:

The respective sensitivity and specificity of CT imaging with traction compared to ICRS grading were 74.4%, and 96.3%. The level of agreement of the ICRS grading between CT images and arthroscopic findings showed moderate (kappa coefficient; 0.547). The diagnosis of grade 3 or 4 lesions had 80.0% sensitivity. Axial traction to CT enabled the delineation of the cartilage surface including chondral thinning, defect and cartilage separation more visible (Figure 1).

Conclusion:

CT with axial traction could obtain acceptable levels of sensitivity and specificity for the evaluation of articular cartilage injuries in addition to the assessment of subchondral bone.
Plantar plating the modified Lapidus arthrodesis
Authors: Pellegrini Manuel , Cuchacovich Natalio , Cortes Aaron , Escobar Freddy , Becerra Eduardo , Doren Alfredo Núñez , Carcuro Giovanni
Published: September 2018

Category:

Midfoot/Forefoot

Introduction/Purpose:

Modified Lapidus arthrodesis is performed in the treatment of different pathologies, including hallux valgus and osteoarthritis of the 1C-MTT joint. Complications of this procedure include delayed union and non – union. To prevent them, several rigid fixation methods have been proposed. Biomechanically, plantar plate fixation may be the best solution. Therefore, we sought to investigate our clinical results and complications in patients operated on with a modified Lapidus arthrodesis using two different plantar plate fixation systems.

Methods:

After IRB approval, we reviewed our prospectively collected database for patients operated on with a modified Lapidus arthrodesis. Dedicated foot and ankle orthopaedic surgeons performed all procedures. Patients were included if they were older than 18 years, had a minimum FU of 1 yr and agreed to participate in the study. Patients with neuropathy, previous surgery, concomitant midfoot/hindfoot procedures or those which fixation method was different from a plantar plate were excluded. Preoperative and postoperative IM angle was evaluated. Two independent musculoskeletal radiologists assessed consolidation under CT scan at 12 weeks postop. Triaxial 2-mm reformatted CT slices were used to calculate joint fusion percentage. Each patient was assigned to a consolidation group considering joint fusion percentage: 0-24%, 25-50%, 51-74%, 75-100%. Intra/interobserver coefficients of variability were calculated. SF-36, SMFA, FAOS and FAAM were obtained preoperatively and at one year follow up. t-test was performed to address for functional outcomes differences in-between groups.

Results:

Twenty-three patients (35 feet) met inclusion criteria. Mean age was 47 years (13-65), 83% female and 17% male. Eleven patients had bilateral surgery. Mean preoperative/postoperative IM angle were 16+3 and 9+2, respectively (p<0.001). Ten feet achieved <24% consolidation (33%) and 20 feet >25% (67%). With the numbers available, consolidation rate didn´t differ in patients undergoing unilateral/bilateral surgery(p=1.0) or plating system(p=0.22). One patient had an anterior tibialis tendon rupture and 1 patient presented an infected non-union, prompting revision. Mean preoperative/postoperative values for SF-36 physical and mental component were 49 and 76(p<0.001); and 43 and 68(p<0.001), respectively. FAOS-pain were 60 and 81(p<0.001);FAOS-daily-life were 59 and 96(p<0.001);FAOS-sport were 43 and 74 (p<0.001);and FAAM-Daily-life score were 67 and 87(p<0.001). No significant differences were found for SMFA.

Conclusion:

Despite a low consolidation rate at 12 weeks post op, patients with plantar plated Lapidus arthrodesis presented a significant increase in functional outcomes and a low revision/complication rate at 1 yr FU. Consideration should be given to delay evaluation under CT scan to 24 weeks post op.
Comparison of Arthroscopic to Open Tibiotalocalcaneal Arthrodesis in High-risk Patients
Authors: Polzer Hans , Braunstein Mareen , Baumbach Sebastian
Published: September 2018

Category:

Ankle Arthritis

Introduction/Purpose:

Patients undergoing tibiotalocalcaneal arthrodesis (TTCA) often suffer from co-morbidities increasing complications such as surgical side infections (SSI) and non-unions. High complications rates following open TTCA led to the development of arthroscopic techniques. Aim of this retrospective case-control study was to compare the results of open to arthroscopic TTCA in high-risk patients.

Methods:

Patient selection was based on the authors’ TTCA database. First, patients treated by arthroscopic TTCA (after 07/2013) using a curved intramedullary nail with a follow-up of >= 1 year were selected. Second, patients receiving open TTCA (prior 07/2013), with comparable co-morbidities and retrospectively suitable for arthroscopic TTCA were identified. Both techniques were conducted in a standardized technique with only the surgical approach differing. Primary outcome parameter were complications within a follow-up of 1 year. Eight open and 14 arthroscopic TTCAs (mean age 59±10 years, 91% male) were included. Patient demographics, indications, co-morbidities, and number of previous surgical interventions were similar for both groups. Three patients in the open and 4 in the arthroscopic group suffered from preoperative plantar ulceration.

Results:

Talar-declination (43°±8° vs. 30°±8°, p<0.001) and calcaneal-inclination angle (6°±10° vs. 18°±6°, p<0.001) improved significantly, comparably in both groups (p=0.183/p=0.393). No significant differences were observed for fusion-rates (75% vs. 64%; p=0.604) or time-to-fusion (15±7 vs. 11±4 weeks; p=0.285). Major complications occurred in 63% of open and 36% of arthroscopic TTCA. For open TTCA, 80% were SSI necessitating multiple revision-surgeries including one below-the-knee-amputation, for arthroscopic TTCA these were solely non-unions. Comparing patients with ulceration to those without, no relevant change in major SSI in open TTCA (67% vs. 60%) could be detected but a pronounced difference in non-union-rates for arthroscopic TTCA (75% vs. 20%). In patients without ulceration the union-rate was 80% for both, open and arthroscopic TTCA.

Conclusion:

Taken together, arthroscopic TTCA drastically reduced major surgical side infections compared to open TTCA in high risk patients. In patients without preexisting ulceration excellent union-rates (80%) for both, open and arthroscopic TTCA could be achieved.
Is it justifiable to perform tibio-talar arthrodesis rather than fixation as the treatment for severe pilon fractures?
Authors: Ramaskandhan Jayasree , Siddiqu Malik , Qasim Sultan
Published: September 2018

Category:

Trauma

Introduction/Purpose:

The purpose of this study was to compare functional outcome at minimum 2 years follow up post fixation of pilon fractures to that of patients undergoing elective procedure (in the form of TAR or ankle arthrodesis) for primary osteoarthritis of the ankle to assess whether pilon fracture patients would benefit from tibio-talar arthrodesis as a primary procedure rather than fixation to avoid significant functional disability between primary fixation and subsequent arthrodesis.

Methods:

This is a retrospective study of prospectively collected data of patients operated between April 2012 and December 2015. All patients with primary osteoarthritis undergoing elective TAR/arthrodesis (Group A) had pre-op functional scores recorded (MOX-FQ, EQ-5D and Foot and ankle outcome score FAOS). Patients with bilateral ankle arthritis, previous reconstructive surgery, inflammatory arthritis, hip and knee arthritis, spinal pathology and underlying neurological conditions were excluded from Group A. Patients in Group B (post Pilon fracture fixation with a minimum 2 year follow up) completed a postal questionnaire with the above scores. Outcomes between groups were compared using inferential statistical tests using SPSS.

Results:

Mean age of patients in Group A and Group B were (62.6 ± 10.9 years) and (46.4 ± 15 years) respectively; p<0.001. In group B, 9 patients (16.6%) had associated injuries and 45 patients (83.3%) had isolated injuries. 49 patients underwent an open reduction and internal fixation vs. 5 patients with hybrid fixator as a definitive management in Group B with 2 patients having significant infection (1 in each group). The results of functional scores comparing Group A to Group B (including sub-group analysis) are awaited and will be submitted subject to acceptance of this abstract.

Conclusion:

The outcomes of pilon fracture are well known to be poor with high rate of secondary osteoarthritis and significant functional disability associated with it in young individuals in active employment. The gold standard treatment for patients with significant osteoarthritis of the ankle is tibio-talar arthrodesis. However, a group of these patients continue to have high functional disability between initial injury and to the point of tibio-talar arthrodesis. The results of this study will highlight the justification to perform tibio-talar arthrodesis as a definitive treatment at the time of injury, rather than fixation.
Evaluating the Subtalar Joint in Tibiotalocalcaneal Nail
Authors: Reilly Megan , Darvish Kurosh , Assari Soroush , Cole John , Wilps Tyler , Gokcen Eric
Published: September 2018

Category:

Hindfoot

Introduction/Purpose:

In tibiotalocalcaneal nails for arthrodesis, the path of the nail through the subtalar joint has not been well documented. Ideally, the defect caused by reaming and the nail does not pass through the joint surface so that the amount of bony contact between the talus and calcaneus is maintained in order to optimize fusion. Our hypothesis is that the TTC nail does not destroy a significant amount contact area between the talus and calcaneus. However, using larger diameter nails (which are inherently stronger) will have more of an effect on the contact surface.

Methods:

Five cadaveric below the knee specimens were obtained. The ankle was disarticulated on each specimen. Subsequently, a guidepin was drilled from the central dome of the talus down to the calcaneus. The 11 mm reamer was then passed over the guidepin through the calcaneus to simulate retrograde reaming of a TTC nail. Then, the subtalar joint was dissected open and the articular surface was documented in comparison with the area that was reamed out. Measurements were then made, using software that calculated two dimensional surface area to determine the percentage of actual subtalar joint area that was reamed out. The mean percentage of articular area that was removed with the reamer was then calculated.

Results:

Among the five specimens, in the calcaneus, the mean total articular area was 599mm2±113 and the mean drilled articular area was 21mm2±16. The percentage of the calcaneal articular surface that was removed with the reamer was 3.4%±1.9. In the talus, the mean total articular area was 782mm2±130 and the mean drilled articular area was 39mm2±18. The percentage of the talar articular surface that was removed with the reamer was 5.0%±2.3. Additionally, an 11 mm reamer makes a circular surface area of 95mm2, and the statistics above indicate that a significant portion of the reamed area is nonarticular, within the calcaneal sulcus or the talar sulcus.

Conclusion:

In a tibiotalocalcaneal nail the subtalar joint is typically incompletely visualized, however this anatomic study demonstrates that the 11 mm reamer eliminates about 3.4% of the calcaneal articular surface and about 5% of the talar articular surface. Therefore, the majority of the articular surface is left intact, which is ideal in optimizing arthrodesis outcomes. Furthermore, this study could extrapolate the effects of a larger nail on the availability of joint surface. It could also be used to argue for cartilage stripping of the affected joint surfaces in arthrodesis preparation, because the majority of the articular surface is, in fact, left intact.
Influence of Foot Position on the Measurement of First Metatarsal Pronation Using the First Metatarsal Axial Radiographs
Authors: Sadamasu Aya , Yamaguchi Satoshi , Nakagawa Ryosuke
Published: September 2018

Category:

Other

Introduction/Purpose:

In hallux valgus (HV) surgery, the importance of correcting first metatarsal (1MT) pronation, as well as correcting adduction, has been increasingly recognized. A 1MT axial radiograph is a simple method to quantify 1MT pronation (see figure). However, this view does not provide the exact axial projection, and 1MT is angled on the image. Furthermore, the 1MT angle is dependent on the foot position and alignment. Therefore the measured pronation angle on the radiograph may not be the same as the “true” pronation along the 1MT long axis. The purposes of this study were to 1) quantify the difference between the measured 1MT pronation on the axial radiograph and the true pronation angle, and 2) determine the influence of foot position on the measurement.

Methods:

CT images of 10 feet from HV patients (HV group; age, 58 years; HV angle, 44°) and 10 feet from those without HV (non-HV group; age, 47years; HV angle, 12°) were obtained. Digitally reconstructed radiographs of the 1MT were generated from the CT images in a three-dimensional virtual space (see figure). 1MT was pronated along the long axis (true pronation angle). Then, images with different plantarflexion (25° to 35° in 5° increments) and adduction (-10° to 10°) angles were created. This procedure was repeated for different pronation angles (-10° to 30°), and 135 simulated 1MT axial radiographs were obtained from each bone. We measured the 1MT pronation angles in all images. Differences in the measured pronation angle and true pronation angle were calculated for each group. Correlations between the measurement difference and 1MT plantarflexion/adduction angles were assessed using the Spearman correlation coefficient.

Results:

The mean measurement differences were 0.7° and 1.0° for the HV group and non-HV group, respectively. The standard errors of the measurement were 0.5° and 0.6° for the HV group and non-HV group, respectively. There was no significant correlation between the measurement difference and plantarflexion angle (P = 0.92 and P = 0.92 for the HV group and non-HV group, respectively), nor between the measurement difference and adduction angle (P = 0.82 and P = 0.74).

Conclusion:

The measurement differences were low in both HV and non-HV feet, indicating that the 1MT pronation angle measured on the axial radiograph represented the true pronation angle along the long axis of 1MT. The measurement differences were consistent regardless of plantarflexion and adduction angles. Therefore, a variation of 1MT angle on the image, which can be caused by the misalignment of foot position while taking the radiograph and difference in foot alignment (such as flatfeet and cavus feet), did not affect the measurement. 1MT axial radiograph could be used as a valid and robust method to quantify 1MT pronation.
Frequency and Impact of Adverse Events in Patients Undergoing Surgery for End-stage Ankle Arthritis
Authors: Sangeorzan Bruce , Coetzee J. Chris , Bohay Donald , Anderson John , Davitt James , Houghton Michael , Maskill John , Brage Michael , Norvell Daniel , Shofer Jane , Ledoux William
Published: September 2018

Category:

Ankle Arthritis

Introduction/Purpose:

Patients seeking surgical treatment for ESAA have two primary treatment options: arthrodesis and arthroplasty. While there are comparative trials that address treatment options, neither the complication risk or the relative effectiveness is clearly established. The focus of this study was to report the magnitude of all AEs (as defined by DSMB) in the peri operative and early healing period after ankle surgery and evaluate the impact of these AEs on patient functional outcomes

Methods:

We report data from a multi-site prospective cohort study performed to compare ankle arthroplasty to ankle arthrodesis in the treatment of ESAA among six participating sites that required AE reporting under FDA required defintions. We compared the risk and impact of non-ankle AEs and ankle-specific AEs versus no AEs controlling for potential confounding factors including surgical procedure using multinomial logistic regression. We estimated differences in post-op functional outcomes by AE occurrence using linear mixed effects regression.

Results:

Among 517 patients who had surgery from 2012 to 2015 and completed the full baseline assessment, follow up was available in 494 (95%) patients. There were 628 reported AEs (477 in the arthroplasty group and 151 in the arthrodesis group), occurring in 261 (63%) arthroplasty patients and 67 (65%) arthrodesis patients. There were 50 (8%) ankle specific AEs. The odds ratio for the risk of an ankle specific AE and non-ankle specific AE versus no AE was 1.84, 95% CI (.85, 3.98) and .96, 95% CI (.57, 1.61), respectively, for those receiving arthrodesis compared to arthroplasty. Patients experiencing ankle-specific AEs had significantly less improvement in FAAM Sports and ADL subscores and worst pain outcomes; however, both groups improved significantly in all measures except mental health.

Conclusion:

Ankle specific AEs were infrequent and only weakly associated with surgical procedure (slightly more in arthrodesis). While patients improved in all functional outcomes except mental health, regardless of AE occurrence, ankle-specific AEs negatively impacted patient improvement compared to those with no AEs or a non-ankle AE.
Double wedge osteotomy and subtalar arthrodesis for rockbottom malunion after calcaneal fracture
Authors: Shi Zhongmin
Published: September 2018

Category:

Hindfoot

Introduction/Purpose:

The pathoanatomy characteristics of the rockbottom malunion after calcaneal fracture include severe loss of calcaneal height, which result in the horizontal of the talus in the ankle mortise and anterior ankle impingement. This study was carreid out to evaluate the clinical results of double wedge osteotomy and subtalar arthrodesis for rockbottom malunion after calcaneal fracture.

Methods:

From February 2014 to February 2015, 9 cases of calcaneal rockbottom malunion after calcaneal fracture were treated with wedged osteomy and subtalar arthrodesis. And 8 patients get final followup. Weight bearing X ray were taken before the surgery and at final followup. Talar declination, lateral talocalcaneal angle, lateral talo-first metatarsal angle and Bohler’s angle were used to evaluate the correction of the malunion. The American Orthopaecid Foot and Ankle Society (AOFAS) ankle-hindfoot scale and visual analog scale (VSA) for pain were collected. SPSS 22.0 software was used for Statistical analysis.

Results:

The average time for bone union was 17.1 weeks (12weeks~22weeks). The talar declination was improved from 2.5 ° (- 6°~13°) preoperatively to 13.25° (5°~19°) postoperatively (P<0.001); the lateral talocalcaneal angle was improved from -0.25° (-15°~10°) preoperatively to 0.25° (7°~25°) postoperatively (P<0.001); the talo-first metatarsal angle was improved from 21.13° (10°~30°) preoperatively to 9.88° (5°~14°) postoperatively (P<0.001); and the calcaneal Bohler’s angle was improved from -25.6 ° preoperatively to 22.4 °postoperatively(P<0.001). The AOFAS scale was 26.63 (12~53) preoperatively, and 79.75 (72~89) at final followup (P<0.001); the VAS scale for pain was 7.5 (6~9) preoperatively, and 2.6 (2~3) at final followup (P<0.001).

Conclusion:

Wedge osteomy and sutalar arthrodesis can effectively correct the malunion, restore the calcaneal height and hindfoor alignment. Pain was relieved after correction, and the function of the ankle and hindfoot was restored.
The LiLiPUT for Ligamentous Lisfranc Injury
Authors: Smith George , Dunne Michael
Published: September 2018

Category:

Trauma

Introduction/Purpose:

The Lisfranc ligament complex is integral to the stability of the 2nd tarsometarsal joint (TMTJ). Injury causes the 2nd metatarsal to displace dorsally and laterally. Injuries are often missed acutely because of subtle findings that are not always apparent on both weight bearing and non-weight bearing radiographs. The concept of the LiLiPUT (Ligamentous Lisfranc Push Up Test) originated from observations during operative cases that dorsal displacement appeared to be the major direction of instability. A sensitive and reproducible out-patient ‘stress test’ for occult Lisfranc injury is, as yet, elusive. The aims of the study were to assess the ability of the LiLiPUT (a raised block beneath the 2nd metatarsal) to reveal an occult ligamentous Lisfranc injury.

Methods:

Ten fresh frozen cadaveric lower limbs were used. Postero-anterior and lateral foot radiographs were obtained prior to simulation of a ligamentous Lisfranc injury via a dorsal approach incising the dorsal and plantar ligaments of the 2nd TMTJ. Radiographs were obtained with: Blocks of increasing size placed underneath the 2nd metatarsal. The foot in 3 different positions of increasing dorsiflexion over the blocks. 10Kg load applied skeletally to the leg over the same blocks and positions. A pressure sensor was at the interface between the 2nd TMTJ and block obtaining pressure maps with maximal load readings for each test.

Results:

The introduction of a 2 x 1 cm block beneath the 2nd metatarsal, with downward force coming from the weight of the amputated limb, revealed an occult injury on the lateral radiographs in 8 of the 10 specimens. A positive test was taken as any discernible dorsal displacement. An increase in block size did not change the force transmitted through the 2nd TMTJ (p=0.32 to 0.42) and had no significant effect on diagnostic yield. Increasing dorsiflexion and increasing load also had no effect on the diagnostic yield. The two specimens without displacement had cavus type foot deformities.

Conclusion:

A small raised block beneath the 2nd metatarsal in a non weight-bearing patient with the foot in a neutral position may be an adequate means of identifying occult ligamentous Lisfranc injuries on lateral radiographs. Further evaluation in the clinical setting is required as this test may not demonstrate instability in the cavus foot variant.
The Effect of Obesity on Achilles Tendon Repair
Authors: Smyth Niall , Hillam Jeffery , Kaplan Jonathan , Aiyer Amiethab
Published: September 2018

Category:

Sports

Introduction/Purpose:

Obesity is increasingly common and has been highlighted as a comorbidity that may negatively impact outcomes following orthopaedic surgery. Operative versus nonoperative treatment of Achilles tendon ruptures continues to be controversial, as operative treatment may slightly reduce the likelihood of rerupture but carries the inherent surgical risks. To further delineate the patients who are at risk of postoperative complications it is of value to determine whether obese patients are particularly vulnerable. The purpose of this study was to determine the effect of obesity on surgical treatment of Achilles tendon ruptures.

Methods:

Patients who underwent a surgical repair of the Achilles tendon were retrospectively identified through the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). The patients were divided into two cohorts (obese and nonobese), and peri and postoperative factors were evaluated for association with obesity.

Results:

A total of 2128 patients were identified, of which 887 (41.7%) were classified as obese. Obesity correlated with an increased operative time, 60.9 minutes versus 56.1 minutes. The only postoperative complication that was associated with obesity was wound healing complication, based on univariate analysis. Multivariate analysis demonstrated obesity was not associated with an increased risk of wound healing complication, infection, deep venous thrombosis, or other systemic complication.

Conclusion:

A large segment of the patient population undergoing Achilles tendon repair is obese. In the current study, although obesity increased the likelihood of developing a wound complication following Achilles tendon repair based on univariate analysis, it was not significantly associated with any other complication.
Clinical Significance of Lateral Ankle Radiograph after the Reduction of a Syndesmosis Injury
Authors: Suh Jae Wan , Kim Sunghyun , Park Hyun-woo
Published: September 2018

Category:

Trauma

Introduction/Purpose:

To introduce reliable and newly developed radiographic measures based on a lateral ankle radiograph to assess a syndesmotic reduction after screw fixation and to compare with the radiographic measures based on the anteroposterior (AP) and mortise radiographs.

Methods:

The postoperative ankle radiographs of 34 ankle fracture cases after screw fixation for concurrent syndesmosis injury were reviewed. Two radiographic parameters were measured on each AP and mortise radiograph; tibiofibular clear space (TFCS) and tibiofibular overlap (TFO). Five radiographic parameters were measured on the true lateral radiographs; the anteroposterior tibiofibular (APTF) ratio, anterior tibiofibular ratio (ATFR), posterior tibiofibular ratio (PTFR), distances of intersection of the anterior fibular border and the tibial plafond to anterior cortex of the tibia (AA’), and the intersection of posterior fibular border and tibial plafond to the tip of the posterior malleolus (BB’). In addition, the distance (XP) between the fibular posterior margin (X) crossing tibial plafond or the posterior malleolus and posterior articular margin (P) of the tibial plafond was measured on the lateral view.

Results:

Using TFCS and TFO in the AP and mortise radiographs, malreductions of syndesmosis were estimated in 17 of 34 cases (50.0%). Using the introduced and developed radiographic measures in the lateral radiographs, syndesmotic malreductions were estimated in 16 out of 34 cases (47.1%). Seventeen cases (50.0%) showed no evidence of postoperative diastasis using the radiographic criteria on the AP and mortise view, 10 cases (58.8%) of whom showed evidence of a malreduction on the lateral radiograph. The newly developed measurements, XP, were measured 0 in 11 out of 34 cases (32.4%).

Conclusion:

The reduction of syndemosis after screw fixation can be accurately assessed intraoperatively with a combination of several reliable radiographic measurements of lateral radiograph and traditional radiographic measurements of AP and mortise radiograph. Using various radiographic parameters selectively, malreduction could be prevented even when some parameters are difficult to measure because of implants or when posterior malleolar fracture is accompanied.
Foot Width Changes Following Hallux Valgus Surgery
Authors: Tenenbaum Shay , Bariteau Jason , Herman Amir , Coifman Oded
Published: September 2018

Category:

Midfoot/Forefoot

Introduction/Purpose:

Hallux valgus is one of the most common deformities of the adult foot, and can adversely affect quality of life, with common complaints including pain, footwear restrictions and cosmesis. Every clinician is familiar with the patients’ concerns regarding the postoperative foot appearance and footwear anticipations. Surprisingly, although patients are concerned with postoperative foot width, there are only scarce reports on this issue. This study was undertaken to evaluate the impact of hallux valgus surgical treatment on foot width.

Methods:

Study included 71 consecutive cases with moderate to severe hallux valgus treated with Scarf osteotomy, distal soft tissue release and Akin osteotomy as needed. Patients were included only if pre- and postoperative weightbearing X-rays at minimum 6 months followup were available. The average age was 55.7 years (range, 20 to 76), with average follow-up of 20.7 months (range, 6 to 96). Patients’ medical records were reviewed for clinical data, surgical technique and radiographic measurements. The radiographic measurements included hallux valgus angle (HVA), intermetatarsal angle (IMA), distal metatarsal articular angle (DMAA), and foot width. Foot width was assessed by measuring both the bony width (BW: maximal distance between the medial cortex of 1st metatarsal head and lateral cortex of the 5th metatarsal head) and the soft tissue width (STW: maximal distance between most medial soft tissue outline and the most lateral soft tissue outline at the level of metatarsal heads).

Results:

Preoperative HV deformity (mean HVA 35.8, IMA 14.1 and DMAA 15.2) was successfully corrected (postoperative mean HVA 13.7, IMA 6.9 and DMAA 7.7). Overall bony foot width was reduced by 5% and soft tissue foot width by 2% postoperatively. Further analysis showed there were 13 feet (18.3%) with increased (>5%) bone width, 26 feet (36.6%) with no change (±5%) and 32 feet (45.1%) for which width decreased in more than 5% postoperatively. Patients with the widest foot before surgery, had a decrease in foot width following surgery whereas, patients with the narrowest foot width, had an increase in foot width. Magnitude of preoperative deformity (as assessed by HVA, IMA and DMMA measurements) or amount of correction had low correlation (<0.2) with postoperative foot width.

Conclusion:

While the ability of surgery to correct HV deformity is well established and reported in the literature, its effect on foot width is less understood or predictable. Overall, the postoperative reduction of foot with was modest. Furthermore, while postoperative foot width (both bony and soft tissue) decreases or does not change in 4 out of 5 patients, there are cases in which foot width actually increases.