bluuebunny/crossref_metadata_2025 huggingface dataset:
Evaluating Outcomes After Midfoot Bone Block Arthrodesis
Authors: Aiyer Amiethab , Shariff Raheel , Tracey Joseph A. , Myerson Mark S.
Published: October 2016

Category:

Midfoot/Forefoot

Introduction/Purpose:

Midfoot arthrodesis requires a structural graft where bone loss from AVN, osteomyelitis and erosive arthritis is present in the navicular, cuneiform or 1st metatarsal. The goal of this study was to evaluate radiographic outcomes of midfoot bone block arthrodesis.

Methods:

A retrospective, IRB approved study was completed evaluating midfoot arthrodesis between 2002 and 2014. where structural bone graft was used as part of an arthrodesis of the tarsometatarsal (TMT) joints or the naviculocuneiform (NC) joints or both. Demographic characteristics were obtained including age, body mass index (BMI), diagnosis, diabetes or tobacco use, indication for use of bone block, location of the bone block, and type of graft used. Radiographic data collected included time to union, the number of patients in which union was obtained, and graft length

Results:

Over a 12-year period, there were a total of 33 with an average age of 57.9 years, and included 20 females and 13 males with an average BMI of 29. The average length of follow up was 24 months. The most common diagnoses was erosive midfoot arthritis (11) and prior navicular fracture associated with AVN (9). Structural allograft was used in all patients. (first TMT (10), talocuneiform (9), other combinations (14)). Various types of biologic agents were used in 20 of 33 arthrodeses. Radiographic evidence of union was found in 21/33 patients (63.6%) at an average of 4.7 months after surgery. Twelve patients developed a nonunion. The risk factors for nonunion include age > 50, the presence of erosive osteoarthritis, AVN of the navicular and lack of use of biologic stimulation. There was no correlation between the presence of diabetes, a prior history of infection or prior history of trauma and development of nonunion.

Conclusion:

The radiographic fusion rate of patients undergoing large structural midfoot bone graft arthrodesis was 63.6% with radiographic evidence of healing present in this group at 4.77 months after surgery. This is the first known study reporting on radiographic outcomes of structural bone graft arthrodesis of the midfoot. The rate of fusion seen here is slightly better compared with recent studies evaluating healing of large defects using femoral head structural allografts. Nonetheless, the risk of non-union remains far greater than when an in situ arthrodesis of these same joints are performed.
Accurate Measurement of First Metatarsophalangeal Range of Motion in Patients with Hallux Rigidus
Authors: Vulcano Ettore , Tracey Joseph A. , Myerson Mark S.
Published: October 2016

Category:

Midfoot/Forefoot

Introduction/Purpose:

The reliability of range of motion (ROM) measurements has not been established for the hallux metatarsophalangeal (MTP) joint in patients with hallux rigidus. The aim of the present study was to prospectively assess the clinical versus radiographic difference in ROM of the arthritic hallux MTP joint.

Methods:

One-hundred consecutive patients who presented with any grade of hallux rigidus were included in this prospective study to determine the hallux MTP dorsiflexion. Clinical range of motion using a goniometer and radiographic range of motion on dynamic xrays was recorded. Inter and intra-rater reliability were calculated.

Results:

The mean difference between clinical and radiographic dorsiflexion was 13°. This difference was statistically significant. For all measurements clinical dorsiflexion was equal or less than radiographically-measured dorsiflexion. The difference was significantly greater in patients with a clinical dorsiflexion of less than 30° than in patients with 30° or more. Radiographic measurement of hallux dorsiflexion had an excellent intra- and inter-observer reliability.

Conclusion:

This study describes a reliable, reproducible, and straightforward method of measuring hallux MTP ROM that eliminates the “human” component of measuring clinical ROM and all the variables that are encountered when making said measurement.
Angular Correction with Chevron-Akin Double Osteotomy in Mild, Moderate, and Severe Hallux Valgus
Authors: Panchbhavi Vinod K. , Lindeman Robert W.
Published: October 2016

Category:

Bunion

Introduction/Purpose:

Hallux valgus affects a substantial number of patients requiring foot and ankle orthopaedic surgery. Chevron osteotomy is commonly used in mild hallux valgus for angular correction, and the chevron-Akin double osteotomy is a more powerful tool, with presumed usefulness in moderate and severe deformity. The objective of this study was to use radiographic analysis to determine the average and maximum corrections achievable with the chevron-Akin double osteotomy.

Methods:

This retrospective study included a total of 30 patients and a total of 33 feet. Pre- and postoperative hallux valgus angles (HVA) and intermetatarsal angles (IMA) were evaluated using standard weight-bearing AP plain x-rays and the differences pre- to post- were calculated. Patients were grouped based on the severity of preoperative hallux valgus into mild, moderate, and severe pathology. The pre- to post- changes of HVA and IMA, and the postoperative values of each angle, were compared between severity groups by using ANOVA, and means and standard deviation were reported at each level of severity. The rate of correction to normal was noted in each severity group. The study was approved by our institutional review board.

Results:

Of the 33 feet, 3 were categorized as mild, 19 as moderate, and 11 as severe. In the mild group, average improvement was 13 in HVA and 6 in IMA; maximum correction achieved was 14 in HVA and 9 in IMA; and 3 of 3 (100%) were corrected to the normal range. In the moderate group, average improvement was 16.5 in HVA and 5.2 in IMA; maximum correction achieved was 29 in HVA and 9 in IMA; and 18 of 19 (95%) were corrected to the normal range. In the severe group, average improvement was 28.5 in HVA and 8.8 in IMA; maximum correction achieved was 43 in HVA and 20 in IMA; and 9 of 11 (82%) were corrected to the normal range.

Conclusion:

This study demonstrates that the combined chevron-Akin double osteotomy is capable of both small and large degrees of angular correction in hallux valgus. It shows that the use of the chevron-Akin double osteotomy can be expanded to cases of moderate to severe angular deformity.
Does Post-Traumatic Arthritis Produce Poorer 5 Year Patient Outcomes Following Mobile-Bearing Total Ankle Replacement?
Authors: Johnson-Lynn Sarah E. , Ramaskandhan Jayasree R. , Siddique Malik S.
Published: October 2016

Category:

Ankle Arthritis

Introduction/Purpose:

Little long term data is available on patient-reported outcome measures (PROMs) following total ankle replacement in patients with posttraumatic osteoarthritis (PTOA), osteoarthritis (OA) and rheumatoid arthritis (RA). Patients with post-traumatic osteoarthritis have previously been felt to have poorer short and long term results following total ankle replacement, due to younger age, higher activity levels and greater patient expectations. We report the 3 and 5 year outcomes for patients who underwent total ankle replacement with a mobile bearing prosthesis, comparing prospectively collected PROMs data for PTOA patients with those with OA and RA.

Methods:

We analysed patient demographic data, American Orthopaedic Foot & Ankle Society (AOFAS) scores, Foot and Ankle Outcome Scores (FAOS), the SF-36 Health Survey, and patient satisfaction scores, collected preoperatively and up to five years postoperatively.

Results:

The study included 109 consecutive patients with total ankle replacement (58 OA, 21 RA, 30 PTOA). At one and two years postoperatively, the PTOA group reported significantly better scores on the general health domain of the SF-36. At three and five years postoperatively, there was a trend for better scores in the PTOA group for all domains of the SF36, however none of these reached significance (P>0.05). At one year postoperatively, the PTOA group and the RA group had better FAOS results for pain than the OA group. There were no significant differences in FAOS scores between groups at three or five years. There were no significant differences in AOFAS scores or in patient reported satisfaction at any measured time point.

Conclusion:

Our findings suggest that patients with posttraumatic osteoarthritis of the ankle can expect comparable five year outcomes after total ankle replacement with a mobile bearing prosthesis as patients with osteoarthritis and rheumatoid arthritis.
Does Smoking Affect Outcome in Surgical Management of Ankle Arthritis? A COFAS Multicentre Study
Authors: Mehta Kinjal , Penner Murray J. , Daniels Timothy R. , Younger Alastair S. , Wong Hubert , Dryden Peter , Wing Kevin , Glazebrook Mark A.
Published: October 2016

Category:

Ankle Arthritis

Introduction/Purpose:

Smoking has been shown to increase complication rates after ankle surgery. The aim of this study was to compare complication rates between smokers and non smokers undergoing surgery for ankle arthritis.

Methods:

Smokers (n=88) and non smokers (n=565) with ankle arthritis who had undergone ankle arthrodesis or ankle arthroplasty were included in the study. Multicentre, prospective data was used from the COFAS ankle arthritis database. Patients with information available on smoking habits and 2 year follow up were included

Results:

There was no significant difference in the overall re operation rates between smokers and non smokers. However, the amputation rate was higher in smokers (3.4%) as compared to non smokers (0.7%). AOS scores and SF 36 scores were similar in the 2 groups. A higher proportion of smokers underwent fusion (46.5%) as compared to non smokers (28.8%). Amputation rate after ankle arthrodesis was higher in smokers (4.9%) as compared to non smokers (0.6%).

Conclusion:

Smokers have a higher amputation rate after ankle arthrodesis or ankle arthroplasty as compared to non smokers. Information from this study can be used during counselling of surgical patients
Effect of Diabetes Mellitus, Peripheral Neuropathy, or Charcot Arthropathy on Workers Compensation Claims
Authors: Grimes J. Speight , Murphree Jefferson J.
Published: October 2016

Category:

Diabetes

Introduction/Purpose:

Charcot neuroarthropathy is a complication of peripheral neuropathy commonly resulting from diabetes mellitus. The actual trigger for a Charcot neuroarthropathy episode is unknown. Due to the chronic nature and multifactorial causality of the disease, affected patients frequently have difficulty with workers’ compensation claims resulting in appeals or even outright denials. This study retrospectively reviewed patient’s charts with workers’ compensation claims in a foot and ankle practice to determine the incidence of diabetes mellitus, peripheral neuropathy, and Charcot neuroarthropathy. The study will then review each affected patient to determine if there is a correlation between his or her health status and claim status.

Methods:

From January 2011 to January of 2015, 331 patients were seen in a tertiary foot and ankle clinic with a worker’s compensation claim. A chart review identified patients with diabetes mellitus, peripheral neuropathy, or Charcot neuroarthropathy. The claims database was reviewed to determine the number of claim appeals submitted for each patient.

Results:

There were 43 patients (13% of workers compensation patients) with diabetes, 12 (4% of workers compensation patients) with peripheral neuropathy, and 3 (7% of diabetics, 1% of workers compensation patients) with Charcot. There were a total of 115 appeals in patients without Diabetes Mellitus, peripheral neuropathy, or Charcot arthropathy, 23 appeals in patient with Diabetes, 8 appeals in patients with peripheral neuropathy, and 6 appeals in the patients with Charcot.

Conclusion:

Diabetes alone did not increase the number of appeals. Patients with peripheral neuropathy, however, were two- times more likely to have an appeal than a patient without peripheral neuropathy. Patients with Charcot had eight times more appeals than patients without Charcot. Thus, Charcot arthropathy and peripheral neuropathy are strong indicators an increased claim appeals in the Worker’s Compensation system. This data only reflects appeals of claims for services provided and does not reflect difficulty with obtaining approvals for planned procedures.
Foot and Ankle Fellowship Websites
Authors: Danna Natalie R. , Hinds Richard M. , Capo John T. , Mroczek Kenneth J.
Published: October 2016

Category:

Other

Introduction/Purpose:

The Internet has been reported to be the first informational resource for many fellowship applicants. Despite being a popular resource, no accessibility or quality standards exist for fellowship websites. The objective of this study was to assess the accessibility of orthopaedic foot and ankle fellowship websites and to evaluate the quality of information provided via program websites.

Methods:

The American Orthopaedic Foot and Ankle Society (AOFAS) and the Fellowship and Residency Electronic Interactive Database (FREIDA) fellowship databases were accessed to generate a comprehensive list of orthopaedic foot and ankle fellowship programs. The databases were reviewed for links to fellowship program websites and compared with program websites accessed from a Google search. Accessible fellowship websites were then analyzed for the quality of recruitment and educational content pertinent to fellowship applicants.

Results:

Forty-seven orthopaedic foot and ankle fellowship programs were identified. The AOFAS database featured direct links to 7 (15%) fellowship websites with the independent Google search yielding direct links to 29 (62%) websites. No direct website links were provided in the FREIDA database. Thirty-six accessible websites were analyzed for content. Program websites featured a mean 44% (range, 5-75%) of the total assessed content. The most commonly presented recruitment content was a program description featured on 94% of fellowship websites. The most commonly presented educational content was a description of fellow operative experience featured on 83% of websites.

Conclusion:

There is substantial variability in the accessibility and quality of orthopaedic foot and ankle fellowship websites. Comparison of the results of our study with those of similar investigations indicates a paucity of fellowship websites presenting comprehensive program information to applicants. Recognition of deficits in accessibility and content quality may assist foot and ankle fellowships in improving program information online.
Frontal Plane Rotation of the 1st Metatarsal in Relation to Arch Height
Authors: Smith W Bret
Published: October 2016

Category:

Bunion

Introduction/Purpose:

There is a question as to the relationship of the effect of the arch height on the frontal plane rotation of the 1st metatarsal, and its impact on hallux valgus deformities. We attempt to evaluate this question and offer an answer for discussion.

Methods:

A series of patients who presented to a single orthopedic foot and ankle clinic with a compliant of hallux valgus deformity received a standardized 4 view standing radiograph series. These included the standard weight-bearing anterior- posterior, oblique, and lateral images. The fourth view was an axial sesamoid view to evaluate the frontal plane rotation. The first 50 patients that met our inclusion criteria were used. Inclusion criteria were skeletal maturity, non-traumatic issue, and primary bunion complaint with no complaint related to the arch. Any patients with prior surgery on the 1st metatarsal or arch structure were excluded. The radiographs where then evaluated by 2 fellowship trained foot and ankle specialist with predetermined radiographic parameters. The included measurements regarding the HAV deformity were IM angle, HAV angle, sesamoid position, DMAA, and axial sesamoid rotation. The measurements captured in relation to arch height included Meary’s angle, talonavicular coverage angle, medial cuneiform arch height, navicular height, and lateral talocalcaneal angle.

Results:

The collected information was then initially checked for inter-observer reliability and found to be consistent between the two observers. Collected values allowed the subjects to be placed into 3 initial categories labeled as planus, normal, and cavus based on the arch measurements. The imaging studies related to the HAV deformity was then classed initially as mild, moderate and severe. The HAV deformities were then further classified based on frontal plane rotation deformity and categorized as rotated, rotated and subluxed, subluxed, or no rotation. All of the individual group measurements were determined and quantified using the same radiographic software and uniform points of measurement. The information was then feed into algorithms that included direct comparisons as well as regression analysis of the defined subsets.

Conclusion:

After review of the data it was noted that there was no significant correlation between arch height measurements, HAV deformity and frontal plane rotation of the 1st metatarsal.
Long-Term Results Of Low Tibial Osteotomy For Ankle Osteoarthritis
Authors: Hio Naohiro , Hasegawa Atsushi , Monden Satoshi , Noguchi Hideo , Taki Masanori , Tsunoda Kazuhiko
Published: October 2016

Category:

Ankle Arthritis

Introduction/Purpose:

There are not many reports about long-term results of low tibial osteotomy (LTO) for ankle osteoarthritis. We mention treatment results for cases in which, among the cases where LTO was performed for ankle osteoarthritis caused by malalignment, tracking was possible for 10 years or more.

Methods:

The study evaluated 11 ankles of 11 patients. Among these were 1 male and 10 females, with a mean age of 57 years, and a mean observation period of 11 years, 5 months. There were 10 joints of 10 patients with varus type osteoarthritis, and 1 joint of 1 patient with valgus type osteoarthritis. For varus type osteoarthritis, in the Tanaka’s X-ray classification, there were 3 joints at stage 2, 2 joints at stage 3a, and 5 joints at stage 3b. As surgical procedures, LTO was performed for 3 joints, LTO with medial malleolar osteotomy was performed for 6 joints, LTO with reconstruction of collateral ligament was performed for 1 joint, and LTO with subtalar arthrodesis was performed for 1 joint. In the clinical evaluation, we used the score of Takakura et al, and in the postoperative radiographic evaluation, we used Tanaka’s X-ray classification.

Results:

Clinical results improved from a preoperative mean of 68.7 points to a one-year postoperative score of 77.2 points, with a score at final observation of 76.3 points. The postoperative radiographic evaluation one year after surgery was Stage 1 in 5 joints, and Stage 2 in 5 joints, but at the time of final observation, the results were Stage 1 in 3 joints, Stage 2 in 4 joints, Stage 3a in 1 joint and Stage 4 in 2 joints. The talar tilting angle had improved, from 9.6° preoperatively to 3.9° at the time of final observation. A strongly positive correlativity was seen between preoperative X-ray classification, arthroscopic classification and X- ray classification at the time of final observation.

Conclusion:

There are no doubt cases where the preoperative severity of the condition has an effect postoperatively, and in the long term, narrowing of the joint space progresses, with clinical results gradually falling, but that progression is gradual, so by performing LTO, it is believed to be possible to maintain functions that adequately tolerate the activities of daily living for that age.
Management of Talar Nonunion With Extensive AVN of the Talar Dome by Resection of Talar Dome, Autograft and Hindfoot Nail
Authors: Abd-Ella Mohamed M. , Farouk Amr
Published: October 2016

Category:

Ankle

Introduction/Purpose:

Extensive avascular necrosis (AVN) and non union are common complications after talar neck fractures especially Hawkin’s grades 3 and 4 and cases associated with comminution of the talar body. When both complications occur together, there is instability due to non union and talar collapse, arthritis of both ankle and subtalar joints, and hindfoot deformity in some cases in the form of varus or equines. The aim in these cases is to get a plantigrade stable painless foot, which requires ankle and subtalar fusion as well as union between the anterior talus and the hindfoot, with no or minimal limb shortening. The purpose is to assess the technique of removing all avascular bone followed by autograft and hindfoot nail to achieve this aim.

Methods:

The study included eight patients, five males and three females with non union of talar neck fractures associated with extensive avascular necrosis of talar dome as a consequence of trauma. The operative technique includes posterior approach to the ankle with tendoachilles splitting (except in one patient where anterior approach was used to remove a tibial plate), removal of all avascular bone until the fracture line is reached, removal of articular cartlilage of ankle and subtalar joints, filling the defect by iliac crest autogenous graft to maintain length and fixation by hindfoot arthrodesis nail. No fixation was used between the graft and the anterior talus. Also, the anterior talus was not fixed to the anterior tibia as this would shorten the limb. The union was assessed clinically and radiologically. The functional outcome was assessed using the AOFAS score. The minimal follow up duration is one year (range: one to five years).

Results:

Six out of eight patients (75%) achieved solid union as evident clinically and radiologically within three to four months. This includes union of the ankle and subtalar joints as well as union between the graft and the anterior talus. Two patients did not achieve union after six months and required another bone grafting. One of them had also non union between the graft and the anterior talus and required additional fixation of the anterior talus. Both cases achieved union after the second procedure. Other complications included one superficial infection and one case of mild equines. The mean AOFAS score improved from 38.8 preoperatively ( range: 22 to 55) to 70.8 in the last follow up ( range: 65 to 86).

Conclusion:

The technique described is a good option in treating cases with talar non union associated with extensive AVN. It has a good union rate and preserves the limb length without the need to proximal bone transport. Posterior approach allows easy access to both ankle and subtalar joints. Our results also suggest that there is no need to fix the anterior talus to the hindfoot as it fuses spontaneously to the graft.
Medium-Term Outcomes Using Fresh Osteochondral Allograft Transplantation for Treatment of Large Osteochondral Lesion of the Talus
Authors: Rungprai Chamnanni , Hartog Taylor Den , Patterson Jason A. , Amendola Annunziato
Published: October 2016

Category:

Ankle

Introduction/Purpose:

Osteochondral allograft has been proven to be successful surgical option for treatment of large osteochondral defect of the talus. However, there are currently limited literatures reported outcomes of this technique.

Methods:

Retrospective Chart review with prospectively collected data of 26 patients with 26 ankles who had been diagnosed with large osteochondral lesion of the talus and underwent fresh osteochondral allograft transplantation 2004 and 2011 in single institution. All patients had failure of conservative treatment and minimum follow-up to be included in this study was 1 year (mean 40.9 months, range, 12 to 123 months). Pre- and post-operative pain (Visual Analog Scale (VAS)), SF-36 (PCS and MCS), and Foot Functional Index (FFI) were obtained and compared using Wilcoxon Singed-Ranks test.

Results:

Twenty-six patients (13 male and 13 female) with mean age of 31.7 years and an average of BMI of 29.0 were included in this study. Complete pre-operative and 1-year post-operative pain (VAS) (n=19/26) and functional outcome scores (SF-36 and FFI)(n=12/26) were collected. The mean pain (VAS) decrease from 6.9/10 to 4.8/10 post-operatively (p = 0.007). The mean SF-36 (PCS and MCS) were 41.3 and 54.7 pre-operatively which improved to 47.2 and 56.0 post-operatively, p = 0.084 and p = 0.875, respectively. The mean FFI (pain, disability, activity limitations, and total score) were 48.0, 48.8, 57.6, and 45.8 pre-operatively which changed to 53.4, 57.6, 68.5, and 54.6 post-operatively (p = 0.674, 0.575, 0.110, and 0.859, respectively). There were 61.8% patient satisfaction with this surgery and 82.7% of the patients will do the surgery again and they will recommend this type of surgery to their friends and family. There were 100% survival rate at 5-year (8 of 8) and 10-year (1 of 1).

Conclusion:

Osteochondral allograft demonstrated significant relief of pain in medium-term of follow-up as measured with VAS. This procedure was successful for treatment of large osteochondral lesion of the talus.
Modified Mitchell Osteotomy Alone Did Not Have Higher Rate Of Residual Metatarsalgia Than Combined First And Lesser Metatarsal Osteotomy
Authors: Chen Shu-Jung , Cheng Yuh-Min , Huang Peng-Ju
Published: October 2016

Category:

Bunion

Introduction/Purpose:

Transfer metatarsalgia (TM) is a common forefoot disorder secondary to hallux valgus (HV), and the best treatment for HV related TM remains controversy. Some authors suggested a combined lesser metarsal osteotomy while undergoing HV surgery, but some authors didn’t agree with it and concluded that isolated HV corrective osteotomy can improve symptomatic metatarsalgia. The main purpose of the retrospective study was to compare clinical outcomes in the patients with and without combined lesser metatarsal osteotomy while they received HV correction surgery.

Methods:

We retrospectively reviewed the patients who underwent osteotomy for HV correction between January 2000 and December 2010. All the patients underwent HV correction with Modified Mitchell osteotomy. Clinical evaluations including the American Orthopaedic Foot and Ankle Society (AOFAS) score and residual metatarsalgia were assessed, and hallux valgus angle, 1st-2nd intermetatarsal angle, metatarsal shortening, and plantar shifting of metatarsal head were measured.

Results:

Sixty-five patients ( 83 feet ) meeting the selection criteria were enrolled. Thirty feet receiving a combined lesser metatarsal osteotomy were grouped as combined surgery group, and the others were grouped as control group ( 53 feet ). The overall rate of persistent symptomatic metatarsalgia was 19.28 % after operative treatment. There were 6 feet with residual metatarsalgia in combined surgery group, and 10 feet in control group. There was no significant difference in the rate of persistent symptoms between groups ( p=0.9).

Conclusion:

According to this result, modified Mitchell osteotomy alone didn’t have higher rate of residual metatarsalgia than combined surgery. Besides, we also found that the average recovery rate of transfer metatarsalgia was about 80.7% and the patients, whose preoperative hallux valgus angle was more than 30 degrees, had the higher risk of residual metatarsalgia after surgery.
Preoperative Patient and Institutional Factors Influence Anaesthetic Type in Foot and Ankle Surgery
Authors: Katchky Ryan , Rofaiel James R. , Rampersaud Yogi R. , Lau Johnny
Published: October 2016

Category:

Other

Introduction/Purpose:

Lower-extremity orthopaedic procedures may be performed under regional or general anaesthesia, or a combination of techniques. There is a growing body of evidence outlining benefits of regional anaesthesia, with meta-analyses of randomized controlled trials and registry data suggesting decreases in surgical site infections, thromboembolism, cardiopulmonary complications and length of stay associated with regional anaesthesia. In patients undergoing foot and ankle surgery specifically, the literature demonstrates decreased pain, nausea, vomiting, opioid use and unplanned hospital admission. This supports increased use of regional anaesthesia in patients undergoing foot and ankle surgery. However, the type of anaesthetic used is dependent on surgeon, patient, anaesthesiologist and institutional factors. The purpose of this study is to investigate pre-operative factors that predict anaesthetic type in patients undergoing foot and ankle surgery.

Methods:

Data was collected prospectively on 888 patients undergoing foot or ankle surgery at a single institution. The primary method of anaesthesia for each procedure was recorded. Ten additional variables were recorded and analyzed: age, BMI, gender, diabetes, ASA status, procedure length, procedure start time, elective vs. trauma procedure, primary vs. revision procedure and preoperative anticoagulation. Logistic regression modelling was performed to identify factors that independently predict the type of anaesthetic used.

Results:

General anaesthetic was employed in 280 patients (32%), and regional anaesthesia was the primary anaesthetic type used in 608 (68%). Logistic regression modelling demonstrated that factors that independently predict use of general anaesthetic include younger age (p < 0.0001; Odds Ratio 0.97/year), male sex (0.0033; 1.618), procedure start time (0.0319; 1.066/hour) and length of procedure ( < 0.0001; 1.520/hour). Patients who underwent general anaesthetic had a mean length of procedure of 108 ± 77 minutes, whereas patient provided with regional anaesthesia had a mean length of procedure 83 ± 64 minutes.

Conclusion:

With increasing evidence supporting use of regional anaesthesia, it is important to identify modifiable factors that contribute to patients receiving alternative treatments. Since later procedure start time was identified as an independent predictor of general anaesthetic use, there may be a role for identifying patients at increased risk of complications associated with general anaesthesia and scheduling earlier start times. Furthermore, while it is logical that extended length of procedure is a contraindication to regional anaesthesia, the mean procedure time of 108 minutes in the general anaesthesia group indicates that many of these patients should still be candidates for regional anaesthesia.
Return to Active Duty Lifestyle After Modified Brostrom
Authors: Melton Thomas J. , Dannenbaum Joseph H. , Ryan Paul M. , Robbins Justin
Published: October 2016

Category:

Ankle

Introduction/Purpose:

Ankle sprains are a common sports related injury and typically treated conservatively. Chronic ankle instability, however, may require surgical management when non-operative measures fail. The Brostrom procedure with Gould modification is the most frequently employed operation for chronic ankle instability with a record of good to excellent treatment outcomes. The purpose of our study was to evaluate the clinical outcomes of this procedure in an active duty population.

Methods:

A retrospective review of our electronic surgery records for a cohort of active duty patients aged 18-45 who were indicated for operative treatment of chronic ankle instability and who underwent surgical repair consisting of a standard Brostrom procedure with Gould modification at Madigan Army Medical Center between January 1,2010 through April 30, 2014 was performed. All patients were treated by a single surgeon and had a minimum of one year follow-up. The electronic medical record was reviewed for each patient to determine their ability to remain on active duty status as well as their permanent lower extremity activity restrictions.

Results:

127 total patients who met the inclusion criteria underwent Brostrom procedures with Gould modification during the study period. 23 out of 127 (18.1%) underwent Medical Evaluation Board (MEB) and separation from active duty for reasons related to their ankle. Another 11 patients underwent military separation for reasons unrelated to their ankle. 67 patients (52.7%) currently have permanent lower extremity profiles in the electronic record. 38 patients with permanent profiles have been able to meet retention standards and remain on active duty status. Of the 93 patients who were able to remain on active duty status, only 2 individuals changed their military occupational specialty (MOS). The remainder of patients remain on active duty status in their current MOS, completed their active duty obligation or reached planned retirement.

Conclusion:

Chronic ankle instability in active duty service members can be severely limiting. Brostrom procedure with Gould modification can provide significant improvement in symptoms and allow patients to remain on active duty status. However, in our high demand population approximately 50% of patients required some form of permanent activity restriction with nearly 20% requiring military separation. This is important information when counseling an active patient population about the expectations from surgical intervention for chronic ankle instability.
Suture-Tape Augmentation for Chronic Ankle Instability
Authors: Gwak Heui-Chul , Kim Jeon-Gyo , Roh Sang-Myung
Published: October 2016

Category:

Ankle

Introduction/Purpose:

This retrospective study was performed to evaluate the clinical outcomes of internal brace technique using suture tape for chronic ankle instability.

Methods:

twenty-three patients were followed for more than 2 years after suture tape augmentation for lateral ankle instability. Twenty five patients were followed for more than 2 years after modified Brostrom procedure. The clinical results after using two techniques were evaluated and compared using Foot and Ankle Outcome Score (FAOS), American Orthopaedic Foot and Ankle Society (AOFAS) score, Olarud and Molander score, Hamilton score and Visual Analogue Scale (VAS). Anterior talar translation and talar tilt angle were obtained from stress radiographs to evaluate the mechanical ankle stability.

Results:

There was no significant difference in VAS at final follow-up (P < .325). There was no significant difference in FAOS at final follow-up (P < .242). There was no significant difference in AOFAS score at final follow-up (P < .418). There was no significant difference in Olarud and Molander score at final follow-up (P < .244). According to the Hamilton score, 14 cases (93%) in internal brace group and 23 cases (92%) achieved satisfactory functional results. Talar tilt angle and anterior talar translation had improved to an average of 2.2 degrees and 4.4 mm in internal brace group and 2.7 degrees and 5.4 mm in modified Brostrom group, respectively, at final follow-up, and there was no significant difference (P < .128, < .226, respectively). There were no complications such as skin irritation and wound infection.

Conclusion:

Suture tape augmentation has shown the potential for stabilizing the lateral ankle ligmament complex as an alternative to direct repair. Functional, objective, and subjective outcomes were excellent in all cases and no complications were seen postoperatively. To confirm the above further, it is appropriate to conduct a larger study.
The Use of a Fibular Nail to Treat Ankle Fractures in Patients With Diabetes
Authors: Younger Alastair S. , Veljkovic Andrea , Penner Murray J. , Wing Kevin
Published: October 2016

Category:

Trauma

Introduction/Purpose:

Patients with diabetes have difficulty healing skin and bone after ankle fractures. A paper published previously demonstrated a much higher rate of wound complications and amputation in patients with diabetes compared to those without diabetes. The purpose of this study was to analyze the outcome of patients with diabetes and ankle fractures prospectively followed using a fibular nail. The primary outcome was bone healing as assessed by CT scan at 12 weeks, and secondary outcomes were outcome scores, reoperation rates, mortality and wound complications.

Methods:

10 patients with diabetes and ankle fractures (Weber b and c, isolated fibula, bi-maleolar and tri-maleolar fractures) were treated with a fibular nail for the fibular fracture, and percutaneous screw fixation for the posterior or medial maleolar fractures. Patients included were those with diabetes with an HBA1c of over 7 or other systemic complications of diabetes. Patients had to survive for 12 weeks after the procedure for inclusion. Excluded were fractures outside the ankle, concomitant injuries, patients unable to follow the study protocol and those with open injuries. The CT scans were assessed on both the Sagittal and Coronal views for bone healing at the fracture site. Each slice was measured for the percent of bone bridging.

Results:

One patient was excluded because of mortality before the 12 week visit. A second patient survived the 12 week follow up and died before 24 weeks. Successful bone bridging was seen in all patients by 12 weeks. The bone bridging was estimated to be 70 +/- 16% (SD) on the sagittal view and 75 +/- 10% on the coronal view at 12 weeks and was on the 82% sagittal view and 80% on the coronal view at 24 weeks. No hardware failure was seen. No fracture failed to unite. There were no mal-unions or non-unions either clinically or radiographically. There was one proximal locking screw wound treated with debridement and antibiotics with successful outcome. This patient developed a charcot arthropathy and underwent ankle fusion.

Conclusion:

This prospective case series demonstrates that the fibular nail can generate successful bone healing and excellent alignment after ankle fractures in patients with diabetes. A further comparative study with plate fixation is merited.
Treatment of Acute Achilles Tendon Rupture with a Standardized Protocol in Normal Clinical Setting
Authors: Haapasalo Heidi , Peltoniemi Ulla , Laine Heikki-Jussi , Mattila Ville M.
Published: October 2016

Category:

Trauma

Introduction/Purpose:

Achilles tendon rupture (ATR) is a common trauma among active people. Recent high-quality randomized studies, have shown that using a standardized treatment protocol with early weight-bearing and controlled early range-of-motion exercises provides similar clinical outcome than operative treatment without surgery-related complications. The purpose of this study was to find out whether the clinical results and complication rates of standardized treatment protocol in normal clinical setting with non-selected population correspond to those achieved in RCT studies.

Methods:

A treatment protocol modified from RCT studies of acute ATR was implemented in standard clinical care of Tampere University Hospital in 2008. Both conservative protocol and postoperative care protocol were based on early weight bearing and early range-of motion exercises. All patients treated due to acute ATR in our hospital during 2008 – 2014 (n=514) were included in the study. The patient records were retrospectively evaluated.

Results:

514 acute ATRs were treated. 407 (79.2%) of the patients were men and 107 (20,8%) women. The mean age of all patients was 47.2 years. In female patients the mean age was 47.0 years, in males 47.9 years. 239 (46%) of the ATRs were treated operatively and 275 (54%) non-operatively. The proportion of operatively treated patients declined from 70% (2008) to 21% (2014). The mean age of patients in the operative group was 39.7 years and 53.7 years in the non-operative group. The rerupture rate was 4.6% in operative and 5.8% in the non-operative group. 10,4% of patients in operative group had wound problems. Unsatisfactory clinical outcome was reported in 5,0% of the patients in the operative group and in 6,9% of the non-operative group.

Conclusion:

Our results show that the treatment of acute ATR in our clinic has changed remarkably during the years 2008 to 2014. In 2008 70% of acute ATRs were treated operatively whereas in 2014 only 21%. Our study shows that it is possible to implement a similar treatment protocol than used in the controlled study setting as a part of the daily clincal care. The most important finding, however, is that the clinical outcome of the patients seems to be fully comparable to the clinical results achieved in RCT-study settings despite the heterogenity of the treated patients and medical staff.
Treatment of Children and Adolescents With Metastatic Medulloblastoma and Prognostic Relevance of Clinical and Biologic Parameters
Authors: von Bueren André O. , Kortmann Rolf-Dieter , von Hoff Katja , Friedrich Carsten , Mynarek Martin , Müller Klaus , Goschzik Tobias , zur Mühlen Anja , Gerber Nicolas , Warmuth-Metz Monika , Soerensen Niels , Deinlein Frank , Benesch Martin , Zwiener Isabella , Kwiecien Robert , Faldum Andreas , Bode Udo , Fleischhack Gudrun , Hovestadt Volker , Kool Marcel , Jones David , Northcott Paul , Kuehl Joachim , Pfister Stefan , Pietsch Torsten , Rutkowski Stefan
Published: October 2016

Purpose

To assess an intensified treatment in the context of clinical and biologic risk factors in metastatic medulloblastoma.

Patients and Methods

Patients (4 to 21 years old, diagnosed between 2001 and 2007) received induction chemotherapy, dose-escalated hyperfractionated craniospinal radiotherapy, and maintenance chemotherapy. Subgroup status and other biologic parameters were assessed.

Results

In 123 eligible patients (median age, 8.2 years old; median follow-up, 5.38 years), 5-year event-free survival (EFS) and overall survival (OS) were 62% (95% CI, 52 to 72) and 74% (95% CI, 66 to 82), respectively. OS was superior compared with the precedent HIT ’91 trial. The 5-year EFS and OS were both 89% (95% CI, 67 to 100) for desmoplastic/nodular (n = 11), 61% (95% CI, 51 to 71) and 75% (95% CI, 65 to 85) for classic (n = 107), and 20% (95% CI, 0 to 55) and 40% (95% CI, 0 to 83) for large-cell/anaplastic (n = 5) medulloblastoma ( P < .001 for EFS; P = .001 for OS). Histology (hazard ratio, 0.19 for desmoplastic/nodular and 45.97 for large-cell/anaplastic medulloblastoma) and nonresponse to the first chemotherapy cycle (hazard ratio, 1.97) were independent risk factors (EFS). Among 81 (66%) patients with tumor material, 5-year EFS and OS differed between low-risk (wingless [WNT], n = 4; both 100%), high-risk ( MYCC/ MYCN amplification; n = 5, both 20%), and intermediate-risk patients (neither; n = 72, 63% and 73%, respectively). Survival rates were different between molecular subgroups (WNT, n = 4; sonic hedgehog [SHH; n = 4]; group 4 [n = 41]; group 3 with [n = 3] or without [n = 17] MYCC/MYCN amplification; P < .001). All cases showed p53 immuno-negativity. There was no association between patients with nonresponding tumors to induction chemotherapy and WNT ( P = .143) or MYCC/MYCN status ( P = .075), histologic subtype ( P = .814), or molecular subtype ( P = .383), as assessed by Fisher’s exact test.

Conclusion

This regimen was feasible and conferred overall favorable survival. Our data confirm the relevance of subgroup status and biologic parameters (WNT/ MYCC/ MYCN status) in a homogeneous prospective trial population, and show that metastatic group 3 patients do not uniformly have poor outcomes. Biologic subgroup, MYCC/ MYCN status, response to induction chemotherapy, and histologic subtype may serve for improved treatment stratification.
Optimizing Pain and Rehabilitation After Knee Arthroplasty: A Two-Center, Randomized Trial
Authors: Choi Stephen , O’Hare Turlough , Gollish Jeffrey , Paul James E. , Kreder Hans , Thorpe Kevin E. , Katz Joel D. , Mamdani Muhammad , Moisiuk Peter , McCartney Colin J.
Published: October 2016

BACKGROUND:

This randomized trial compared (1) continuous femoral nerve block (cFNB), (2) single femoral nerve block (sFNB), and (3) local infiltration analgesia (LIA) with respect to analgesic and functional outcomes after primary tricompartmental knee arthroplasty (TKA).

METHODS:

One hundred twenty patients undergoing primary tricompartmental knee arthroplasty were randomly assigned to 1 of 3 interventions for postoperative analgesia: (1) cFNB—preoperative bolus of ropivacaine 0.5% 20 mL followed by ropivacaine 0.2% 5 mL per hour for 48 hours; (2) sFNB—preoperative bolus of ropivacaine 0.5% 20 mL with placebo 0.9% saline 5 mL per hour for 48 hours; or (3) LIA—intraoperative tricompartmental injection of ropivacaine 0.2% (150 mL) with epinephrine (10 µg/mL) and ketorolac 30 mg with femoral placebo 0.9% saline 20 mL preoperative bolus and 0.9% saline placebo 5 mL per hour for 48 hours. All participants received an identical, standardized, postoperative multimodal analgesic regimen. Participants, health care providers, data collectors, and analysts were blinded. All participants received identical perineural catheters and perineural/LIA solution (depending on randomized intervention) to maintain blinding. The primary outcome measure was numeric rating scale for pain (NRS) during physiotherapy on postoperative day (POD) 2 at 9:00 am. Secondary outcomes included opioid consumption, NRS on POD 1 (rest/physiotherapy/worst), functional outcomes, and block complications.

RESULTS:

For the primary outcome, pain during physiotherapy on POD 2 at 9:00 am, the overall analysis of covariance (ANCOVA) was significant (P = .049), but pairwise comparisons did not demonstrate any significant differences between treatment arms. NRS was 4.6 (95% confidence interval [CI], 3.3–6.0) for the cFNB group, 4.6 (95% CI, 3.3–6.0) for the sFNB group, and 3.4 (95% CI, 2.2–4.8) for the LIA group. The following is the mean difference in NRS on POD 2 at 9:00 am among groups: cFNB−LIA (1.2, 95% CI, −0.1 to 2.5; P = .073); sFNB−LIA (1.2, 95% CI, −0.2 to 2.5; P = .097); cFNB−sFNB (0.0, 95% CI, −1.3 to 1.4; P = .996). There were no statistically significant differences between groups in cumulative 48-hour opioid consumption or functional outcomes. cFNB and LIA were superior to sFNB for NRS on POD 1 for worst pain experienced and pain during physiotherapy, respectively. There were no adverse events associated with study procedures reported among participants in the 3 groups.

CONCLUSIONS:

Our findings suggest no clinically significant differences between cFNB, LIA, and sFNB for pain during physiotherapy on POD 2 after TKA. Secondary analyses suggest that cFNB and LIA are superior to sFNB for early analgesic outcomes (NRS on POD 1) after TKA.
Building Comprehensive Strategies for Obstetric Safety: Simulation Drills and Communication
Authors: Austin Naola , Goldhaber-Fiebert Sara , Daniels Kay , Arafeh Julie , Grenon Veronique , Welle Dana , Lipman Steven
Published: October 2016

As pioneers in the field of patient safety, anesthesiologists are uniquely suited to help develop and implement safety strategies to minimize preventable harm on the labor and delivery unit. Most existing obstetric safety strategies are not comprehensive, lack input from anesthesiologists, are designed with a relatively narrow focus, or lack implementation details to allow customization for different units. This article attempts to address these gaps and build more comprehensive strategies by discussing the available evidence and multidisciplinary authors’ local experience with obstetric simulation drills and optimization of team communication.