bluuebunny/crossref_metadata_2025 huggingface dataset:
Tissue Biopsy in Infected Foot and Ankle Surgery
Authors: Abdalla Samir , Makki Daoud , Elgamal tarel , Harvey David , Jackson Gillian , Platt Simon R.
Published: October 2016

Category:

Basic Sciences/Biologics

Introduction/Purpose:

When performing surgical debridement to treat chronically infected orthopaedic cases our unit routinely samples 5 intraoperative specimens for microbiology. Best practice and achieving accurate sampling would suggest that a new scalpel and forceps for each sampling site would yield the most valid results.The alternate option would be to use the same instruments. The aim of this prospective study was to compare the two techniques in treating infected foot and ankle cases.

Methods:

Ten consecutive patients undergoing debridement for foot and ankle infection were prospectively included. Both techniques were performed on same patient to minimise any bias related to the type of host and severity of infection. This was achieved by collecting 5 tissue samples from 5 different sites initially using fresh instruments for each . We then used the first scalpel and forceps to sample the 2nd, 3rd, 4th, and 5th sites again. Samples were labelled from 1 to 9 where the 6th to 9th samples were from the same sites as the 2nd to 5th samples but taken by different technique. This allowed differentiating a genuine growth at a particular site from a contaminant carried on from another site.

Results:

In 7 patients the scalpel transferred microorganisms from one site to another as some of the 5 sites showed no organisms when biopsied by fresh instruments but showed growth when sampled by the re-used first scalpel. In the remaining 3 patients, the growth form the sites sampled by re-used first scalpel was consistent with the growth from those sites when ampled by fresh instruments .

Conclusion:

Our preliminary results showed that fresh scalpel and forceps are required for each sampling site to avoid transferring contamination from one site to another. This helps guide the extent of future debridement and also the type of antibiotics to be used.
Resection Arthroplasty for Limb Salvage in Severe Unreconstructable Charcot Joints
Authors: Gotha Heather , Brodsky James W. , Taniguchi Akira , Shen Wei
Published: October 2016

Category:

Diabetes

Introduction/Purpose:

When non-operative treatment of very severe Charcot neuroarthropathy (CN) of the ankle and hindfoot fails, surgical options for limb salvage are limited. Some patients have insufficient bone stock or medical and psychosocial factors that make arthrodesis untenable. Resection arthroplasty can create a braceable, plantigrade ankle and foot, preserving the limb and maintaining ambulatory independence. This study evaluated the results of resection arthroplasty and bracing as an alternative technique of limb salvage in the subset of patients who would otherwise require amputation for unreconstructable Charcot deformity.

Methods:

The medical records and radiographs of 16 patients who underwent resection arthroplasty for unreconstructable Charcot deformity from 2000-2014 were retrospectively reviewed. All had diabetic peripheral neuropathy. The average follow-up was 46.75 months (range 9-111 months). Data included demographics, medical history, ambulatory status, and soft tissue lesions. Radiographs were categorized according to the Brodsky Charcot classification. Pre-operatively, 2 patients were community ambulators without assistive device. Four patients were wheelchair bound. Ten patients (62.5%) had limited ambulatory independence, as either home ambulators or reliant on assistive devices, such as crutches and walkers. At the time of surgery, 87% had presence of persistent and recalcitrant ulceration as a result of their deformity. Fifteen patients (93%) had Brodsky Type 2 (Hindfoot) or Type 3 (ankle) Charcot joints. Primary outcomes assessed were limb survivorship and ambulatory status at last follow-up. Secondary outcomes included wound complications, infection, and need for subsequent surgical procedures following index procedure.

Results:

Kaplan-Meier survivorship probability estimate for limb salvage at 5 years following resection arthroplasty was 93% (95% CI 66%-99%). A total of 4 resection arthroplasties ultimately failed, requiring BKA. Three out of 4 amputations occurred after 5 years of successful function. Of the 12 patients who retained their limb at final follow-up, all had braceable deformity without evidence of skin breakdown or infection at the time of final follow-up. Eleven of the 12 were independent community ambulators with bivalved AFO (BAFO). With regard to overall changes in ambulatory status following resection arthroplasty, all patients who were independent community ambulators pre-operatively maintained their ambulatory independence post-operatively with use of BAFO. For patients who were either non-ambulatory or dependent ambulators pre-operatively, 10/14 (71%) achieved ambulatory independence.

Conclusion:

Resection arthroplasty with long-term post-operative bracing is an effective alternative technique for limb salvage and preservation of ambulatory independence in the subset of CN patients who would otherwise likely require amputation for unreconstructable deformity.
Timing of Antibiotic Prophylaxis for Preventing Surgical Site Infections in Foot and Ankle Surgery
Authors: Tantigate Direk , Jang Eugene , Seetharaman Mani , Noback Peter C. , Heijne Anna M. , Greisberg Justin , Vosseller J Turner
Published: October 2016

Category:

Other

Introduction/Purpose:

Surgical site infection (SSI) is one of the most troublesome outcomes after any surgery, for both patient and surgeon. In addition to significant morbidity for patients, SSIs have been hallmarked as an important metric in value-based purchasing by CMS. Surgical literature has suggested that 15-60 minutes prior to incision is the ideal timing of intravenous antibiotics. The purpose of this study is to find the optimal timing of antibiotic administration before foot and ankle surgery, as well as to elucidate the risk factors for SSIs.

Methods:

An a priori power analysis was performed in order to detect a 4% absolute increase in infection rate with delayed timing of antibiotic prophylaxis, based on a presumed baseline SSI rate of 4% in foot and ankle surgeries based on literature on healthy patients undergoing foot and ankle surgery (n=1204 to achieve a power of .80). A retrospective chart review of 1933 foot and ankle procedures in 1632 patients over 56 months was performed. Demographic data, type and amount of antibiotics, timing of antibiotic administration, incision time, and closure time were recorded. The incidence of subsequent wound infection and subsequent incision and drainage procedure (I&D) within 30 days and 90 days were documented. Comparison of outcomes and demographic variables between the group of patients who received preoperative antibiotics less than 15 minutes before incision, and those who received them between 15 to 60 minutes prior to incision was performed.

Results:

A total of 1569 procedures met inclusion criteria. There were a total 17 cases (1.1%) of subsequent wound infection, of which 11 required a subsequent I&D within 90 days. There were 59 additional cases (3.8%) of wound complications which did not meet SSI criteria. When antibiotics were administered between 15 and 60 minutes prior to incision, there was a 2.7-fold, statistically significant higher rate of SSIs as compared to the group of patients receiving antibiotics < 15 minutes before incision (p < 0.05). When comparing the patients who had subsequent SSIs to those who did not, the only significant independent predictors were longer surgeries and non-ambulatory surgeries (both p < 0.05). When a stepwise multivariate logistic regression was performed to see which variables would predict an SSI, it was found that 91.8% of the risk of an SSI could be predicted by ASA score and length of surgery alone.

Conclusion:

In foot and ankle surgeries, the timing of intravenous antibiotic prophylaxis does not appear to play as large of a role as in other surgical subspecialties. Our studies revealed that host factors length/complexity of surgery may play a much larger role in determining the rate of infections than the timing of antibiotic prophylaxis.
Reduced Bacterial Growth on Titanium Screws With Nanophase TiO2 Surface Treatment
Authors: Bhardwaj Garima , Parekh Selene G. , Webster Thomas J.
Published: October 2016

Category:

Other

Introduction/Purpose:

An important strategy in the reduction of orthopedic infections is to develop implant materials that prevent initial bacteria adhesion and growth onto implant surfaces. Bacterial localization and biofilm formation may lead to acute and chronic infections[1]. Biofilm formation on implant surfaces protects bacteria from the immune system and antibiotic therapy, thus, requiring an aggressive treatment of antibiotics that frequently do not work post biofilm formation[2]. Thus, to prevent implant infections, various strategies have been developed aside from conventional systemic and local antibiotic treatment. Recently, there has been increasing interest for coating implants with other materials to improve osseointegration and prevent infection, chronic inflammation, and unwanted foreign body responses[3]. The current study focuses on modifying the surface of titanium implants by treating them with nanophase titanium dioxide using electrophoretic deposition.

Methods:

Nanophase titanium dioxide was synthesized using a wet chemical synthesis and was deposited on Ti-6Al-4 V titanium screws using a cathodic arc deposition plasma system. Bacterial assays were conducted using Staphylococcus aureus (ATCC® 29740™), Pseudomonas aeruginosa (ATCC® 39324™) and an ampicillin resistant strain of E. coli (BIO-RAD Strain HB101 K-12 #166-0408 and pGLO Plasmid #166-0405). 0.03% tryptic soy broth (TSB) (Sigma Aldrich, Cat # 22092) and agar (Sigma-Aldrich, Cat # A1296) were used as the media and colony forming assays were performed to determine bacterial adhesion.

Results:

Nanophase titanium dioxide was successfully synthesized and applied onto the desired surface. A statistically significant decrease in bacterial adhesion was observed across all 3 strains of bacteria; an example of confocal images for S. Aureus is given in figure 1. In addition, decreased macrophage functions and increase osteoblast functions were also observed in the nano TiO2 treated Ti6Al4 V screws. Importantly, this was all achieved without the use of drugs and/or antibiotics decreasing the chance for the spread of antibiotic resistant bacteria and drug side effects.

Conclusion:

The screws were successfully coated using EPD and reduced bacterial adhesion on the coated surface was observed.
Adductor Canal Block Versus Femoral Nerve Block for Anesthesia of Hindfoot and Ankle Surgery
Authors: Park Young-uk , Choo Ho-Sik , Park Jangho
Published: October 2016

Category:

Other

Introduction/Purpose:

Femoral nerve block (FNB) has been commonly used for anesthesia and analgesia in patients undergoing foot and ankle surgery as well as sciatic nerve block. (SNB) However, its effect on motor function, related fall risk and impact on rehabilitation has been the source of controversy. Adductor canal block (ACB) potentially spares motor fibres of the femoral nerve, but the comparative effect on foot and ankle surgeries of the two approaches has not yet been well defined due to considerable variability in pain perception.The authors hypothesized that ACB, compared with FNB, would exhibit less quadriceps weakness and demonstrate noninferior pain score at surgery and at 2 to 24 hours after the operation.

Methods:

Sixty patients scheduled for hindfoot and ankle surgeries (arthroscopy, achilles tendon surgery, medial ankle surgery) were randomised (stratified randomization for each surgery) to receive ultrasound-guided FNB or ACB in addition to combined SNB. The primary outcome was motor strength.(manually and via dynamometer) Secondary comparative outcomes included pain scales at each stages, time profiles (during procedure, time to full anesthesia, time to start recovery, time to full recovery, operation time), dose of ansthetics, complications and patient satisfaction. Degree of pain was measured using VAS (Visual Analog Scale) scores at the operation, 30 minutes after surgery, and at 2 h, 1 day, and 2 days after surgery.

Results:

Thirty patients received ACB; 30 patients received FNB. At 30 minutes to 2 h postanesthesia, ACB patients had significantly higher average dynamometer readings versus FNB patients (39.7±21.1, 37.5±18.3 vs 0.0±0.0, 0.0±0.0), but was not inferior to FNB at 24 and 48 hours. There were no significant differences were seen between two groups at any time point with regard to pain in the quantitative comparison using visual analogue scale (VAS) scores, motor strength, dose of anesthetics, time profiles or patient satisfaction.

Conclusion:

Adductor canal block preserved quadriceps muscle strength better than FNB, without a significant difference in postoperative pain. ACB may represent a safer alternative to FNB.
Randomized Controlled Trial of Intense Therapeutic Ultrasound for the Treatment of Chronic Plantar Fasciitis
Authors: Latt L. Daniel , Christensen Dallin N. , McNelly Ashley L. , Slayton Michael H. , Amodei Richard C. , Fastje Cindy D.
Published: October 2016

Category:

Sports

Introduction/Purpose:

Initial treatment of plantar fasciitis (PF), consisting of anti-inflammatories, stretching and in-shoe orthosis (heel pad, heel wedge, or arch support), leads to symptomatic resolution in over 90% of patients but takes 3-6 months. This study was conducted to test the effectiveness of a minimally invasive modality, intense therapeutic ultrasound (ITU), in accelerating the healing of chronic plantar fasciitis (PF). ITU uses high-frequency high-intensity focused ultrasound to create small thermal injury zones inside soft tissue without damage to surrounding structures. ITU has been shown to initiate a tissue repair cascade and promote collagen generation in dermal and musculoskeletal tissue and is FDA approved for use in non-surgical brow lifts [1,2]. The goal of this study was to determine if ITU when combined with standard therapy could speed the healing of chronic PF.

Methods:

47 patients with chronic (greater than 3 months) heel pain due to PF were randomized to standard therapy (anti- inflammatory pills, stretching, and gel heel cups) plus ITU (“ITU”, n=33) or standard therapy plus sham ITU (“control”, n=14) groups. ITU treatments were administered at enrollment and two-weeks later using a custom 3.3 MHz therapeutic ultrasound system (Guided Therapy Systems, Mesa, AZ). Sham treatment utilized the same protocol but with the energy set to 0 Joules. Treatment effect was assessed at 2, 4, 6, and 12 weeks after the initiation of treatment using diagnostic ultrasound and patient reported outcomes (PROMIS physical function computer adaptive test, PROMIS global health, Foot Function Index pain subscale, and a non-validated heel pain specific questionnaire). Ultrasound images were analyzed to determine the size of lesions within the PF. Both the sonographer and the study coordinator administering the patient reported outcome instruments were blinded to group assignment.

Results:

38 patients completed the 12 week study (ITU: n=37, Control: n=11.). The ITU group reported a significantly greater reduction in heel pain scores [Mean 8.27, SD 4.69, P=0.027] compared to the control group [Mean 2.25, SD 5.92] (Figure 1). Ultrasound imaging showed an 81% decrease in perifascial lesion size in the treatment group, compared to a 26% increase in lesion size in the control group (Figure 2).

Conclusion:

Preliminary results of this clinical study of noninvasive ITU for the treatment of chronic PF showed that ITU treatment as compared to sham control lead to a larger and more rapid reduction of heel pain and perifascial lesion size. ITU holds promise as a potential therapy to accelerate the healing of chronic plantar fasciitis
Arthroscopic Deltoid Ligament Repair
Authors: Acevedo Jorge I. , Mangone Peter
Published: October 2016

Category:

Arthroscopy

Introduction/Purpose:

Background: Recent studies have underscored the importance of open repair of the deltoid ligament for rotational ankle instability in purely ligamentous injuries as well as with ankle fractures. With the advent of successfull arthroscopic lateral ligament techniques the authors have explored the use of similar arthroscopic techniques for deltoid repair. This study aimed to describe a novel arthroscopic technique for deltoid ligament repair and relate the proximity of anatomic structures at risk. Purpose: To evaluate the proximity of anatomic structures for a novel arthroscopic deltoid ligament stabilization technique and to define ideal landmarks and “safe zones” for this repair.

Methods:

Methods: Five human cadaveric ankle specimens were screened for the study. All specimens underwent arthroscopic deltoid ligament repair with a suture passer and suture anchor technique. Five cadaveric specimens were dissected to determine the proximity of anatomic structures after repair. Several distances were measured, including those of different anatomic structures to the suture knot to determine the “safe zones.” Measurements were obtained and statistical analysis was performed.

Results:

Results: None of the specimens revealed entrapment of the suture knots to the posterior tibial tendon (PTT) or saphenous nerve. The safe zone between the PTT and saphenous vein was a mean of 20 mm (range, 16-25 mm). On average, a 16 mm (range, 12-20 mm) safe distance was maintained from the suture knot to the PTT. The saphenous vein was in close proximity to the suture knot at a mean distance of 3 mm (range, 0-9 mm).

Conclusion:

The results indicate that there is a relatively wide safe zone between the PTT and the saphenous vein when performing the arthroscopic deltoid ligament stabilization technique. While none of the critical anatomic structures (except for saphenous vein) were entrapped by the suture knot, it was evident that the variable course of the saphenous vein renders it at risk for entrapment. This study further defines the proximity of adjacent anatomic structures and establishes the anatomic safe zones for the arthroscopic deltoid ankle stabilization procedure. By defining this relatively risk-free zone, surgeons less experienced with arthroscopic ligament repair techniques may approach arthroscopic suture passage with more confidence.
Blood Transfusion During Total Ankle Arthroplasty is Associated With Increased In-Hospital Complications and Costs
Authors: Smith Kenneth S. , Ewing Michael A. , Ponce Brent A. , Johnson Michael D.
Published: October 2016

Category:

Ankle Arthritis

Introduction/Purpose:

Total ankle arthroplasty (TAA) is an effective treatment for end-stage ankle arthritis and is increasing in utilization. Need for blood transfusion is one potential complication of TAA. While numerous studies have associated blood transfusions with increased complications in hip and knee arthroplasty, little is known of its effect in TAA. This study aims to use a large nationally representative database to determine the effect of blood transfusion on inpatient complications and total hospital costs following TAA.

Methods:

Using the Nationwide Inpatient Sample (NIS) database from 2002-2012, 19,190 patients undergoing TAA were identified, with 294 (1.5%) receiving a blood transfusion. Univariate analysis was performed to determine patient and hospital factors associated with blood transfusion during inpatient stay following TAA. Multivariate analysis was performed to determine if blood transfusion was associated with other inpatient complications after controlling for age, race, gender, and comorbidities.

Results:

Patients receiving a blood transfusion were more likely to be older, female, African American race, on Medicaid insurance, and in a non-teaching hospital. The average length of stay for patients undergoing blood transfusion was 5.4 days compared to 2.5 days for those who did not (P < 0.001), while the average inpatient cost was $101,214.77 vs. $58,076.23. Blood transfusion was associated (P < 0.001) with acute renal failure, acute myocardial infarction, pneumonia, length of stay and inpatient cost greater than 75th percentile. After controlling for age, race, gender, and comorbidities, blood transfusion was determined to be an independent risk factor for acute renal failure (P=0.001, OR=3.17), acute myocardial infarction (P < 0.001, OR=66.76), extended length of stay (P < 0.001, OR=5.82), and increased inpatient cost (P < 0.001, OR=2.68).

Conclusion:

Peri-operative blood transfusions are associated with increased inpatient complications and increased hospital costs following total ankle arthroplasty. Careful preoperative assessment and medical optimization of these patients should be performed in order minimize the risk of peri-operative blood transfusion.
Comparison of Early Functional Rehabilitation and Cast Immobilization after Minimally Invasive Repair of an Acute Achilles Tendon Rupture
Authors: Park Young-uk , Choo Ho-Sik , Lim Seongyeon
Published: October 2016

Category:

Hindfoot

Introduction/Purpose:

The optimal treatment for acute Achilles tendon ruptures is still a subject of debate. Operative repair of an acute Achilles tendon rupture (ATR) reduces the risk of re-rupture and has therefore gained popularity as a standard treatment for ATR. There is ongoing controversy over the best surgical technique and postoperative treatment. The purpose of the present study was to compare the outcomes of patients with an acute Achilles tendon rupture treated with minimally invasive repair and early functional rehabilitation with the outcomes of similar patients treated with cast immobilization.

Methods:

41 patients were enrolled in this study. All included patients underwent minimally invasive surgery, after which a below-knee splint with the foot in 120 degrees of plantar flexion was applied for the first week. Patients were then divided to the cast immobilization group (IG) or to the functional group (FG). The ankle in the IG was immobilized in a fiberglass cast in 110 degrees of plantarflexion during next 1 week and in 100 degrees in next 1 week and neutral position with full weightbearing in weeks 3 to 4. From the second week, patients in the FG were mobilized, full weightbearing, in a CAM Walker boot with weekly removing heel wedges. (first wedge removed at 2 weeks, second wedge removed at 3 weeks, third at 4weeks) Data were collected during the outpatient checks at 6 weeks; 3 and 6 months; and 1 year.

Results:

There was no clinically important difference between groups with regard to heel height, range of motion, return to work or sports, calf circumference, VAS, AOFAS, ATRS except ROM difference at 6weeks and heel height at 3 months. Rerupture occurred in one patient in each group.

Conclusion:

The minimally invasive repair of ATR was a safe and reliable technique with good results. Early mobilization and weightbearing seemed to be as safe as more traditional postoperative immobilization with similar functional result and complications.
Does Ankle Arthritis Cause More Disability Than Other Pathologies of the Foot and Ankle?
Authors: Siddique Malik S. , Ramaskandhan Jayasree R. , Ashworth Nicola
Published: October 2016

Category:

Ankle Arthritis

Introduction/Purpose:

Ankle arthritis is been extensively studied for disease severity and outcomes of surgery. It is a condition resulting in significant pain and disability. There is a lack of literature on pain and disability in ankle arthritis compared to other pathologies of the foot and ankle. We aimed to study the level of disability caused due to ankle arthritis and how it compares to other commonly reported conditions of the foot and ankle.

Methods:

We collected PROMs using MOX-FQ questionnaire from newly diagnosed patients under the care of 1 consultant from May 2014 to July 2014. Data was collected for 13 commonly reported conditions for forefoot (3), midfoot (3), hindfoot (5) and ankle arthritis. We grouped patients as Group A, B, C and D for forefoot, midfoot, hindfoot disorders and ankle arthritis respectively. The responses to each of the 3 domains of MOX-FQ were analysed using statistical tests for analysis of variance.

Results:

136 patients took part in this study. There were 52 patients with ankle arthritis, 56 patients with forefoot conditions (19- big toe arthritis, 18 - hallux valgus and 19 – morton’s neuroma/metatarsalgia); 22 patients with midfoot disorders (15 – TMT joint arthritis, 4 – TNJ arthritis and 3 – CC joint arthritis) and 31 patients with disorders of hindfoot (9 – STJ arthritis, 6 – tib post pathology, 4 – plantar fasciitis, 3 – Haglund’s disease and 3 – achillis tendinitis). Although patients with hindfoot problems reported a trend for higher pain scores (72.0) when compared to groups A (62.6), B (64.7) and D (66.2), this failed to achieve statistical significance.Group D patients reported highest scores for difficulty with walking/standing (p=0.008) and similar levels of pain to other foot conditions (p>0.05). For Social interaction domain, all 4 groups reported similar level of restrictions in social activity, (p=0.679).

Conclusion:

Patients with ankle arthritis experienced higher levels of difficulty with walking and standing and similar levels of pain and restriction with social activities to patients with other foot and ankle pathologies. Further research is required to explore general health and functional limitations in lines with ICF (International Classification of Function and Disability) for ankle arthritis. (We aim to present a breakdown of pain, walking/standing and social function domains by each foot condition in comparison to ankle arthritis in the event of this abstract being accepted)
Early Weight Bearing on a Fixed Syndesmosis. Does it Matter?
Authors: Mocoçain Pablo P. , Ortiz Cristian A. , Wagner Emilio E. , Keller Andres A.
Published: October 2016

Category:

Trauma

Introduction/Purpose:

Introduction: There is no consensus about when to allow weight bearing in ankle fractures in which a screw was used to maintain reduction of the syndesmosis. There has been no evaluation, of the radiographic fate of the syndesmosis when syndesmotic screws are retained and early weight bearing is encouraged. The aim of this study was to evaluate the radiographic parameters of the syndesmosis over time in patients who had a screw fixation of the syndesmosis and early weight bearing was allowed.

Methods:

We analyzed 42 patients with ankle fractures treated in our institution, with at least one syndesmotic screw in which early weight bearing was allowed (3 weeks postoperatively). Weight bearing radiographs were obtained at 2 weeks, 2 months and at final follow up (41.2 months). We measure medial clear space (MCS), tibiofibular overlap (OL), tibiofibular clear space (CS) and talar shift (TS).

Results:

At final follow up, 66,6% of the screws were broken, 30,9% showed significant loosening and only 1 patient (4,7%) had a screw that remained solid with no signs of osteolysis. MCS at 2 weeks, 2 months and at final follow up was 2,94 mm; 3,03 mm; 3,02, respectively. OL was 6,76 mm; 6,78 mm; 6,83 and CS was 4,26 mm; 4,66 mm; 4,6 mm. No TS was detected. There was no difference in measurements along time (p>0,05). Also no difference was found in measurements within patients with intact versus broken screws (p>0,05).

Conclusion:

Early weight bearing on a fixed syndesmosis appears to be safe, with no measurable consequences on plain X rays regarding ankle joint parameters. Despite screw breakage or loosening on x-rays, loss of reduction is seldom observed. We believe aggressive functional rehabilitation after ankle fractures including early weight bearing is beneficial for our patients and may lead to improved functional results.
Effects of Variations in Dwyer Osteotomy Determined by 3D-Printed Patient-Specific Modeling
Authors: Weinheimer Kent T. , Aydogan Umur , Lewis Gregory S. , Roush Evan P.
Published: October 2016

Category:

Hindfoot

Introduction/Purpose:

Dwyer osteotomy is commonly used in surgical correction of heel varus deformity but few studies have reported on the size of wedge removed, and none have reported on location of the osteotomy or angle at which the osteotomy should be made. The purpose of this study is to determine these optimal parameters for surgical correction in patients undergoing Dwyer osteotomy using pre-operative imaging analysis with 3D-printed modeling.

Methods:

Patients with hindfoot varus deformity who had undergone Dwyer calcaneal osteotomy in a single institution were evaluated. Pre-operative CT scans were used to create a 3D-printed model of the ankle and foot sparing the calcaneus. Multiple identical calcaneus models were 3-D printed to perform different variations of the osteotomy. Osteotomies were done at 10, 15 and 20 mm distal to the posterior calcaneal tuberosity at 3 different angles of 30, 45, and 60 degrees of obliquity and taking out 5 or 10 mm of bony wedge giving us 18 osteotomies for each patient. After fixation, each model was mounted to a fixed platform and posterior and Harris heel views was obtained. The angle between the tibial-talus axis and calcaneal-tuber axis was measured digitally and compared to pre-osteotomy state. We used paired t-test to compare corrections (Figure 1).

Results:

54 osteotomies were done on 3 patient specific models. We focused on angles 30 and 45 degrees cuts. 60 degree cuts were excluded from the study, because most of them were impossible to do due to anatomical landmarks. The average degree correction of deformity per mm of bone resected was found to be 2.99 degrees in the posterior view and 1.84 degrees in the Harris Heel view. This correction was not statistically different between 30 and 45 degree cuts or between the location of the osteotomy from the posterior calcaneal tuberosity.

Conclusion:

This is the first study that a 3D-printed model was used in the analysis of pre-operative imaging prior to Dwyer osteotomy to help determine optimal realignment of the hindfoot. The average degree of correction per mm bone resected was 2.99 degrees in the posterior view and 1.84 in the Harris heel view. A 60 degree cut is not advised because it is not possible for many of the iterations due to limitations of the calcaneal or peroneal tuberosity. This study provides insight into the amount needed to resect to correct the deformity, but the optimal position varies between the patients.
First Tarsometatarsal Joint Mobility in Hallux Valgus
Authors: Kimura Tadashi , Kubota Makoto , Taguchi Tetsuya , Suzuki Naoki , Hattori Asaki , Marumo Keishi
Published: October 2016

Category:

Bunion

Introduction/Purpose:

Hypermobility of the tarsometatarsal (TMT) joint has been much debated, but is considered to be an important factor in hallux valgus. However to date, studies investigating such hypermobility have been limited to two-dimensional (2D) evaluations using plain X-ray images or to mobility in the sagittal plane. Three-dimensional evaluation should offer more accurate pathological information given that deformity of the hallux valgus occurs in three dimensions. This study evaluated mobility of the first TMT joint in 3D using weight-bearing computed tomography (CT) and an original weight-bearing device (Figure) and then examined its correlation with the hallux valgus angle and intermetatarsal angle in hallux valgus patients.

Methods:

Ten feet of 10 hallux valgus patients and 10 feet of 10 healthy volunteers without foot disease (control group)were examined. Mean age of the two groups was 58.2 years and 55.9 years, respectively. The hallux valgus angle was 43.2° and 14.1° and the intermetatarsal angle was 22.1° and 9.3°, respectively. CT was performed under two conditions: non-load with the ankle in a neutral position and full-body weight-bearing load. Three-dimensional models of each bone were reconstructed by segmentation, the positions of each bone were adjusted, and the extent of first metatarsal displacement relative to the medial cuneiform was measured in 3D. We defined orthogonal coordinate axes(X-axis, Y-axis, Z-axis), the motion around the X-axis, Y- axis, and Z-axis was defined as plantar flexion/dorsiflexion, inversion/eversion, and adduction/abduction respectively. Data were compared between the hallux valgus and healthy control groups using Student’s t-test. In hallux valgus patients, mobility of the first TMT joint was compared with the hallux valgus angle and intermetatarsal angle using Pearson’s correlation coefficient.

Results:

Dorsiflexion (X-axis), inversion (Y-axis), and adduction (Z-axis)were significantly different between the hallux valgus patients and control subjects (p < 0.05). In the hallux valgus patients, there was no large correlation between mobility of the first TMT joint and either hallux valgus angle (X-axis: г=0.21 p=0.55, Y-axis: г=0.11 p=0.75, Z-axis: г=0.10 p=0.78) or intermetatarsal angle (X-axis: г=0.40 p=0.25, Y-axis: г=0.10 p=0.78, Z-axis: г=0.53 p=0.11).

Conclusion:

We were able to analyze 3D changes in the load on the foot in detail. Hallux valgus patients showed hypermobility of the first TMT joint not only in dorsiflexion (sagittal motion), but also in inversion and adduction. However, larger hallux valgus and intermetatarsal angles did not affect mobility of the first TMT joint. Therefore, the magnitude of hallux valgus deformity may correlate with other joint mobility or complex mobility of first ray. Our technique and findings help to clarify the nature of the pathology of hallux valgus and should assist in the selection and development of treatment methods.
Gas Formation and Its Effect After Implantation of Bioabsorbable Metal Magnesium
Authors: Kim Jong-Kil , Jeong Seong-Yup , Lee Kwang-Bok
Published: October 2016

Category:

Basic Sciences/Biologics

Introduction/Purpose:

Metallic biomaterials (stainless steel and titanium) are most commonly used for osteotomy and fusion surgery in foot and ankle. But it results in the physical and psychological burden to the patients owing to the second surgery (hardware removal). Bioabsorbable polymer has the disadvantages such as mechanically weak strength and osteolysis. To overcome these, bioabsorbable metal such as magnesium (Mg) implant have been developed recently and applied clinically, but it has also drawback such as gas formation by the biodegradation of magnesium alloys. However, there is no study on the characteristics of the gas formation and its effect on the surrounding tissue. The purpose of this study is to identify the characteristics of gas formation and histological reaction during the absorption of Mg on surrounding tissue using in vitro and in vivo rodent model.

Methods:

Pure Mg plate (15 × 15 × 2 mm) was immersed in EBSS (Earle’s balanced salt solution) for in vitro immersion test for 30 days. Intramuscular implantation of Mg plate (25×5×0.25 mm) was performed on twenty-four rat’s back muscle and divided as two groups: implantation and sham surgery. Gas volume and compositions, corrosion rate and surface morphology of Mg plate, and histological exam were evaluated at every 5 days for 30 days.

Results:

Gas is mainly composed of H2 (2.483 ×104± 0.028 μV), but a small amount of CO (93.428±0.14 μV) and CO2 (57.18±0.53 μV) was detected in in vitro immersion test. Gas volume shows significantly higher at 5 days (0.084 ml) than other times (0.005 mL for 30 days) after implantation, and is gradually decreased over time. Corrosion rate is also faster in at 5 days and decreased over time in both in vitro and in vivo study. Surface morphology shows a lot of cracks and the formation of apatite paticles on Mg plate. Histological examination shows that nuclei gathered densely around the small and multiple air bubble pocket at 5 days and the number of gas bubbles and their volumes were reduced over time in tissue surrounded implant, and there is no difference in kidney and liver tissue between implant and sham surgery.

Conclusion:

The immersion of Mg in EBSS generated H2 as the major forming gas, and CO and CO2. The in vivo implantation of Mg into rats’ back muscle generated gas pockets inside the tissues because the initial gas formation rate was faster than the gas- absorbing rate; however, gas volume decreased after 15 days as the gas formation and absorbing rates became similar. The amount of Mg ions inside the liver and kidneys changed as well, but it was within a normal range, such that inflammation and tissue deformation were not found.
How Reliable is Clinical Evaluation in Hindfoot Coronal Alignment?
Authors: Slullitel Gaston , Alvarez Victoria , Calvi Juan P. , Calvo Ana B.
Published: October 2016

Category:

Hindfoot

Introduction/Purpose:

Hindfoot alignment in the coronal plane is an extremely important aspect to consider in order to make a comprehensive evaluation of different foot and ankle disorders. To the authors knowledge the evidence concerning the precision of clinical hindfoot alignment assessment is scarce. The aim of this study is to evaluate correlation and reproducibility between clinical and radiographical hindfoot alignment.

Methods:

Intra and interobserver reliability of clinical and radiographical hindfoot assessment was performed in 85 patients. Clinical alignment was evaluated on photographs taken at the time of presentation and hindfoot alignment was quantified on long axial view radiographs in neutral rotation position. Photographs were classified into three categories (valgus, neutral and varus) and radiographs were measured taking standardized parameters. Each observer made measurements independently and was blinded to both patient identification and the others’ measurements. All measurements were made on two separate occasions with the order of images randomized.

Results:

We did not observe a significant correlation between clinical and radiographical assessment (k1a 0,072 - p=0,24; k1b 0,167 - p=0,029; k2a 0,23 - p< 0,001; k2b 0,137 - p=0,021). We did find a good clinical and radiographical intraobserver agreement (K1= 0,789; K2=0,783; Pearson1= 0,956; Pearson2= 0,990). Clinical interobserver agreement was moderate (K1= 0,584; K2=0,566) while radiographical interobserver agreement was statical significant (Pearson1= 0,926; Pearson2= 0,953).

Conclusion:

Due to a poor clinical-radiographical correlation we should not rely on clinical evaluation to guide the decision making in different foot and ankle conditions. We strongly recommend the use of the long axial view in order to assess the magnitude of the hindfoot deformity.
Management of Osteochondral Lesions of the Talus Using Autologous Chondrocyte Implantation
Authors: Gross Christopher E. , Erickson Brandon J. , Fillingham Yale A. , Hellman Michael D. , Adams Samuel B. , Parekh Selene G.
Published: October 2016

Category:

Arthroscopy

Introduction/Purpose:

Osteochondral lesions of the talus (OLT) are frequent occurrences when patients sustain both traumatic and atraumatic ankle injuries with a report rate of up to 70% OLT in patients who sustain an ankle sprain or fracture. Surgical treatment options for OLT is either reparative or replacement and are dictated by characteristics of the lesion, including size and presence or absence of cysts. Periosteal-autologous chondrocyte implantation (P-ACI) or MACI (matrix-induced autologous chondrocyte implantation) is useful for lesions with or without cysts under 2.5cm2. We hypothesize that MACI will have the lowest reoperation rate and highest patient satisfaction rate in treating OLT.

Methods:

A systematic review was registered with PROSPERO and performed with PRISMA guidelines using three publicly available free databases. Therapeutic clinical outcome investigations reporting OLT outcomes with levels of evidence I-IV were eligible for inclusion. All study, subject, and surgical technique demographics were analyzed and compared between continents and countries. Statistics were calculated using Student’s t-tests, one-way ANOVA, chi-squared, and two-proportion Z-tests.

Results:

Nineteen articles met our inclusion criteria, which resulted in a total of 343 patients. Six studies pertained to arthroscopic MACI, 8 to open MACI, and 5 studies to open PACI. All studies were Level IV evidence. Due to study quality, imprecise and sparse data, and potential for reporting bias, the quality of evidence is low. In comparison of open and arthroscopic MACI, we found both advantages favoring open MACI (AOFAS and MOCART score). However, open MACI had higher complication rates versus arthroscopic (18.18% vs 0.78%, p = 0.002). In addition, the rate of impingement was noted to be significantly higher for the open technique of MACI with a rate of 10.61% as opposed to 0.78% for the arthroscopic technique (p = 0.01).

Conclusion:

No procedure demonstrates superiority or inferiority between the combination of open or arthroscopic MACI and PACI in the management of OLT less than 2.5 cm2. Ultimately well-designed randomized trials are needed to address the limitation of the available literature and further our understanding of the optimal treatment options.
Measurement Properties of Total Ankle Replacement Outcome Measures
Authors: Pinsker Ellie , Inrig Taucha M. , Daniels Timothy R. , Beaton Dorcas
Published: October 2016

Category:

Ankle Arthritis

Introduction/Purpose:

Researchers and clinicians measuring outcomes following total ankle replacement (TAR) are challenged by the wide range of outcome measures used in the literature without consensus as to which are valid, reliable, and responsive in this population. This review identifies region- or joint-specific outcome measures used for evaluating TAR outcomes and synthesizes evidence for their measurement properties.

Methods:

A standard search strategy was conducted of electronic databases MEDLINE, EMBASE and CINAHL (to June 2015) to identify foot/ankle measures in use. A best evidence synthesis approach was taken to critically appraise measurement properties [COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN)] of identified measures. The review was restricted to English publications and excluded cross-cultural adaptations. Measurement properties collected from each article were coded for validity, reliability, responsiveness, or interpretability. Psychometric evidence exists for identified measures tested in non-TAR populations, but were not the focus of this review.

Results:

The search identified five measures to include in the best evidence synthesis, which have undergone psychometric testing in a TAR population (Foot Function Index, Ankle Osteoarthritis Scale, American Orthopaedic Foot and Ankle Society Ankle- Hindfoot Scale, Foot and Ankle Outcome Score, Self-Reported Foot and Ankle Score). Methodological quality of the studies providing psychometric evidence was assessed: (1) Validity—Two good quality studies examining different measures provide moderate evidence supporting construct validity (SEFAS; FFI, AOS, AOFAS *subjective items); (2) Reliability—two good quality studies examining different measures provide moderate evidence supporting internal consistency and test-retest reliability (FFI, AOS, AOFAS*; FAOS, SEFAS); (3) Responsiveness—one fair quality study provides limited evidence for AOFAS*, AOS, FFI; (4) Interpretability—two studies provided interpretability values (AOS, FFI, AOFAS*).

Conclusion:

This review offers a basis for choosing the most appropriate instrument for evaluating TAR outcomes. Numerous outcome measures were identified with evidence supporting their use in populations with various foot/ankle conditions, but none have strong evidence supporting usage in a TAR population. Outcome measures must have adequate psychometric properties in all patient groups in which they are applied. Evidence supporting or critiquing an instrument should not be based on studies with poor quality methodology, as identified by this review. Further testing in a TAR population would benefit identified measures with emphasis on adequate sample sizes, testing a priori hypotheses, and evaluating their content validity for a TAR population.
Modified Broström Procedure for Chronic Ankle Instability with Generalized Joint Hypermobility
Authors: Park Jae Yong , Kim Hyong Nyun , Park Yong Wook
Published: October 2016

Category:

Sports

Introduction/Purpose:

Chronic ankle instability with generalized joint hypermobility (GJH) is considered a contraindication for the modified Broström procedure. The most widely accepted definition of GJH is a Beighton-Horan score of ≥4 on a 9-point scale. However, it is not clear if this criterion can be applied to determine the GJH that would lead to a poor outcome after the modified Broström procedure.

Methods:

The modified Broström procedure was performed in 32 patients with chronic ankle instability with GJH, if the contralateral uninjured ankle showed a normal varus talar tilt and anterior talar translation during the stress tests. We hypothesized that when the contralateral uninjured ankle shows a normal varus talar tilt and anterior talar translation during stress tests in patients with GJH, GJH may have a smaller effect on the ankle ligaments, and the modified Broström procedure in these cases may have satisfactory outcomes. The mean patient age at surgery was 21.7 years. The mean follow-up duration was 27.4 months.

Results:

The Karlsson-Peterson ankle score significantly improved from 63.6 ± 7.1 points (p< 0.001; 95% CI, 22.1 – 29.7) preoperatively to 90.4 ± 6.7 points at the final postoperative follow-up. Sixteen patients were very satisfied with the results, 10 patients were satisfied, 3 patients rated their satisfaction as fair, and 1 patient was dissatisfied with the results. We stratified the clinical outcomes according to the Beighton scores. There was no correlation between the Beighton scores and the Karlsson- Peterson ankle scores at the last follow-up (Spearman’s correlation coefficient, -0.11; p= 0.591). However, 1 patient with a Beighton score of 8 points and 1 patient with a score of 9 points had lower Karlsson-Peterson ankle scores (82 and 85, respectively) compared to the average scores at the last follow-up.

Conclusion:

The modified Broström procedure was successful in patients with chronic ankle instability with GJH, if the contralateral uninjured ankle showed a normal varustalar tilt and anterior talar translation during the stress tests. The repaired ligaments may eventually stretch out in patients with GJH secondary to connective tissue disorders such as Marfan syndrome as these patients have been found to have inherent connective tissue extensibility. However, GJH includes mild joint hypermobility without any symptoms or problems except increased joint range of motion. When the contralateral normal ankle shows negative stress tests that the modified Broström procedure may be successful.