bluuebunny/crossref_metadata_2025 huggingface dataset:
Hallux Valgus Patients, Why Are They Happy?
Authors: Baca Emre , Karaali Evren , Duramaz Altuğ , Ercin Ersin
Published: September 2017

Category:

Bunion

Introduction/Purpose:

AOFAS score and angular changes are used widely to assess hallux valgus surgery. But our previous study showed us that these parameters do not reflect patient subjective satisfaction after surgery, angular changes do not correlate with patient satisfaction, and a subjective satisfaction scale must be used. So can we find a measurable parameter that reflects patient satisfaction? The purpose of the study was to evaluate the effect of percental reduction of first web space length (FWSL) on patient satisfaction, and if it can be used as a measurable parameter for this.

Methods:

Fifty feet of thirty-seven patients were included to the study. All patients were operated between 2010 and 2014. Same surgical technique (Lindgren-Turan osteotomy)used for operations. Patients were evaluated by using hallux valgus angle (HVA),1-2 intermetatarsal angle (IMA), first web space length (FWSL), AOFAS scores. On the final follow-up they were asked to scale their postoperative satisfaction between 1-10;as for 1-2 very unsatisfied, 3-4 unsatisfied, 5-6 neither unsatisfied nor satisfied, 7-8 satisfied, 9-10 very satisfied. The percental changes of HVA, IMA, and FWSL were compared with AOFAS score, and satisfaction scales.

Results:

Average age was 45,50±12,23 (22-68) years. Mean follow-up was 41,68±14,46 (24-68) months. 29 of 50 feet were right side, 21 were left. Preoperative HVAs have been changed from 32,52±5,19 to 11,58±4,70 degrees (p=0,001; p<0,01). Preoperative IMAs have been changed from 15,00±3,56 to 5,75±2,45 degrees (p=0,001; p<0,01). Preoperative AOFAS scores have been changed from 75,04±5,54 to 93,14±6,25 points (p=0,001; p<0,01). Preoperative FWSL changed from 14,5 (10-22) mm to 7,5 (5-14) mm (p=0,001; p<0,01). Postoperative satisfaction scale was 8,60±0,67 (7-10) points. When HVA and IMA percental changes were compared with AOFAS percental changes, they have shown a negative statistical significance according to Spearman’s Correlation Analysis. When AOFAS percental changes have been compared with satisfaction scale, they have shown a positive statistical significance. When FWSL percental changes were compared with AOFAS percental changes and satisfaction scale it has shown a positive statistical significance for both parameters according to Spearman’s Correlation Analysis.

Conclusion:

According to our results; we believe that the changes of FWSL have an influence on patient satisfaction. It is correlated both with AOFAS, and subjective satisfaction scale. It can be used as a measurable parameter to search for patients satisfaction. Angular changes do not have an influence on patients satisfaction. May be FWSL should also be used for surgical indications?
Time to Diagnosis and Treatment of Superficial versus Deep Incisional Surgical Site Infections in Foot and Ankle Surgery
Authors: Baranek Eric , Tantigate Direk , Jang Eugene , Noback Peter , Greisberg Justin , Vosseller J. Turner , Seetharaman Mani , Heijne Anna
Published: September 2017

Category:

Ankle

Introduction/Purpose:

Surgical site infections (SSI) are among the most expensive healthcare-associated infections and result in a substantial psychosocial and financial burden for both patients and the healthcare system. A majority of SSIs are estimated to be preventable. Previous literature has focused on antibiotic prophylaxis as the primary intervention to reduce the incidence of SSI. However, little work in the foot and ankle literature has been done on the characterization and risk stratification of patients who will go on to develop superficial versus deep incisional SSIs. Moreover, the time at which patients typically present with an SSI has not been characterized. The primary aim of this study was to quantify the time from surgical intervention to the onset of superficial versus deep SSI.

Methods:

A retrospective review of 1933 foot and ankle procedures in 1632 patients from January 1, 2011 through August 31, 2015 was performed. Demographic data, type of surgery, subsequent diagnosis of superficial or deep incisional SSI, as well as amount and timing of antibiotic administration, incision, tourniquet and closure time were recorded. Superficial incisional SSIs were defined as those successfully treated with antibiotic therapy alone. Deep incisional SSIs were defined as those requiring subsequent wound irrigation and debridement (I&D). Time to treatment, outcomes and demographic variables were compared between patients that were treated with antibiotics alone and those that required I&D for definitive management.

Results:

1569 procedures with complete data met inclusion criteria. There were 17 deep incisional SSIs (1.1%) that required I&D as part of definitive management. There were 63 superficial incisional SSIs (4.0%) that were treated successfully with antibiotics alone. The time interval between surgery and the initial treatment of deep incisional SSI (range: 11 to 42 days) was significantly greater than the time interval between surgery and initial treatment of superficial incisional SSI (range: 4 to 38 days) (28.18 ± 9.11 vs. 13.40 ± 4.65 days, p=<0.001). A total of 11 of 17 (64.7%) infections ultimately diagnosed as deep incisional SSIs failed a trial of antibiotics prior to I&D, in the remaining 6 of 17 (35.3%) infections antibiotics were held until intra-operative wound cultures were obtained.

Conclusion:

In our cohort of patients undergoing foot and ankle surgery the time to initial diagnosis and treatment of deep incisional SSI was longer than the time to diagnosis and treatment of superficial incisional SSI. Moreover, deep infections did not present until four weeks after surgery on average; this data is of some benefit in trying to define and understand SSIs.
Hallux Motion
Authors: Barber Collin , McLaren Alex , Castaneda Paulo , Shoshan Dor
Published: September 2017

Category:

Bunion, Trauma, Other

Introduction/Purpose:

Immobilization is required for management of acute and chronic pathologic states of the hallux metatarsophalangeal (MTP) joint. Traditionally, this was performed using physician applied custom splint or cast and achieved a high degree of immobilization. Braces and orthotics are becoming less expensive and have several advantages, such as light weight and convenience in removal. However, this may come at the expense of ability to restrict movement. We hypothesize that generic braces will provide as much immobilization as custom applied plaster splints.

Methods:

Healthy volunteers were instrumented with electromagnetic sensors over bony prominences of the right foot. Range of motion exercises and activities of daily living were performed without an immobilization device. The same procedure was repeated with each of three immobilization devices: a post-operative shoe, a walking boot, and a custom applied plaster splint. Position and angular data were collected to determine range of motion primarily of the hallux MTP joint. This study was approved by the hospital IRB

Results:

Compared to baseline, all three immobilization devices significantly reduced range of motion at the MTP joint in non- weight bearing with the ankle in dorsiflexion and plantarflexion (p<0.05). There was no significant difference detected between the devices. There was no significant difference in hallux motion during the standing exercise in any of the immobilization devices compared to baseline. During stance phase of gait, all three devices reduced range of motion at the MTP joint compared to baseline (p<0.05), though there was no statistically significant difference between devices.

Conclusion:

Consistent with the hypothesis, data from this study show that all both generic devices and the physician applied splint reduced range of motion compared to baseline. Unfortunately, the study was not powered enough to detect significant differences between the devices, though there was a trend towards the walking boot providing more immobilization.
Early Clinical and Radiographic Outcomes of Trabecular Metal Total Ankle Using Transfibular Approach
Authors: Barg Alexej , Saltzman Charles
Published: September 2017

Category:

Ankle, Ankle Arthritis

Introduction/Purpose:

In the last two decades, total ankle replacement (TAR) has gained more acceptance as a treatment option in patients with end-stage ankle osteoarthritis. However, there is a lack of literature on TAR using a lateral transfibular approach. Therefore, we sought to report early clinical and radiographic results of a patient cohort treated with TAR using a lateral transfibular approach by a single surgeon.

Methods:

Fifty-five primary total ankle arthroplasties using the Zimmer trabecular metal implant were performed in 54 patients (29 men and 25 women; mean age, 67.0 years) from October 2012 to December 2014. Clinical assessment including pain evaluation and measurement of ankle range of motion was done preoperatively and at the latest follow-up. Weight-bearing radiographs were used to determine the angular alignment of the tibial and talar components and to analyze the bone-implant interface. Intraoperative and postoperative complications, revision surgeries, and failures were evaluated.

Results:

Implant survival was 93% at 36 months follow-up. There were 3 revisions of a tibial component due to aseptic loosening. In 10 of 55 procedures, a secondary procedure was performed during follow-up. Mean follow-up duration was 26.6 ± 4.2 months. No delayed union or non-union was observed for fibula healing. The average VAS pain score decreased significantly from 7.9 ± 1.3 to 0.8 ± 1.2. The average total range of motion increased significantly from 22.9° ± 11.8° to 40.2° ± 11.8°.

Conclusion:

Early results of Zimmer trabecular metal total ankle replacement demonstrated improved patient-reported outcomes and increased ankle motion at a minimum follow-up of one year. In the first 55 consecutive cases, the fibular osteotomy required for access to the ankle healed without complications. Painful early loosening requiring revision due to lack of bony ingrowth was seen in 3 of 55 cases.
A Supine Achilles Tendon Repair Decreases Total Operating Room and Anesthesia Time Without Sacrificing Outcomes
Authors: Beck David , Raikin Steven , Pedowitz David , Zmistowski Benjamin
Published: September 2017

Category:

Ankle, Sports, Trauma

Introduction/Purpose:

Achilles tendon repairs have traditionally been performed using a prone position. Prone positioning gives the surgeon easy visualization of the tendon, but may not offer the safest position for anesthesia and requires more peri-operative positioning time. We propose that the use of a supine position for primary Achilles tendon repairs offers similar surgical times, while saving non-surgical operating room time during positioning and anesthesia set-up.

Methods:

A retrospective review of primary Achilles tendon repairs done at our institution’s surgical sites between March of 2010 and July of 2015 was performed. Using the institutional database, 145 procedures were identified. Chart review demonstrated that 82 were performed open-supine (OS), 31 were performed open-prone(OP), and 32 were performed percutaneous-prone(PP). Surgical, non-surgical, and total operating room times were compared between the three groups.

Results:

Average surgical times were 32.8, 49, and 32.3 minutes for the OS, OP, and PP procedures, respectively. Total operating rooms times were 59.1, 88.9, and 76.7; while non-surgical times spent in the operating rooms were 26.3, 39.9, and 44.4 minutes for these groups, respectively. Achilles tendons repaired either OP or PP resulted in an additional 13.6 and 18.1 (average 15.9) minutes of operating room time. There was not an increase in complications with the supine procedure compared to the prone procedures.

Conclusion:

Primary Achilles tendon repairs can be performed effectively using an open technique in a supine position, saving non-surgical operating room time without increasing complications. The supine position may also offer a safer method of providing anesthesia to these patients by allowing the anesthesiologist a more accessible airway and decreasing the risks involved with placing an intubated patient into a prone position.
Bridge Plate Fixation Results in Better Functional Outcomes Than Transarticular Screw Fixation for Low-Energy Lisfranc Injuries
Authors: Bellamy Joseph , Cochran Grant
Published: September 2017

Category:

Midfoot/Forefoot, Sports, Trauma

Introduction/Purpose:

Open reduction and internal fixation (ORIF) with transarticular screws or bridge plating is the standard of care for unstable Lisfranc injuries. There are no studies comparing the clinical outcomes of fixation with transarticular screws or bridge plates in young, athletic patients who sustained low-energy injuries.

Methods:

All low-energy Lisfranc injuries that underwent ORIF between 2010 and 2015 were reviewed. Injuries were classified as low-energy if the occurred during athletic activity, ground level twisting, or a fall from less than three feet (typically stairs or curbs). Tarsometatarsal (TMT) joint fixation with transarticular screws or bridge plating was documented. Transarticular screws were typically removed between four and six months postoperatively. Injury characteristics, complication rates, pain scores, and Foot and Ankle Ability Measure (FAAM) scores were compared. All continuous variables were compared with a two-tailed Student t-test. All categorical variables were compared using the Chi Squared test.

Results:

Of the fifteen patients identified, nine were fixed with transarticular screws and six with bridge plates. Average patient age was 27 years old. 12 of 15 were primarily ligamentous injuries. Implant removal was performed in the entire transarticular screw group and three out of six in the bridge plate group (p=0.018). Secondary arthrodesis for arthritis was recommended in two of the transarticular screw group and none of the bridge plate group (p=0.21). Mean FAAM scores were significantly higher in all subscales (ADL 96.2 v 76.7 p=.035, ADL SANE 92.5 v 72.6 p=.055, Sport 89.5 v 62.5 p=.027, Sport SANE 90 v 58.7 p=.024) in the bridge plate group at an average of 43 months follow up.

Conclusion:

In this study, ORIF with bridge plate fixation of the TMT joints had a lower rate of HWR and higher medium term FAAM scores than fixation with transarticular screws. A statistically significant difference in rates of secondary arthritis could not be established in this small cohort. Prospective studies are necessary to confirm these findings.
Clinical Outcomes of Screw Fixation for Ligamentous Injuries to the Ankle Syndesmosis in Athletes
Authors: Chambers Monique , Kromka Joseph , Hogan MaCalus
Published: September 2017

Category:

Sports

Introduction/Purpose:

Injuries to the ankle syndesmosis are commonly seen in the general population as well as in athletes [1]. Literature is mixed on the effectiveness of the two fixation techniques – rigid screw and suspensory fixation [2]. Specifically, data is lacking in an athletic population. Hypothesis: We hypothesize that in patients treated with rigid screw fixation, athletes will have a higher incidence of hardware-associated pain, screw breakage, and screw removal compared to non-athletes.

Methods:

This study was a retrospective review of a patients from eight orthopedic surgeons within the UPMC system. All patients underwent surgical stabilization of the ankle syndesmosis with a rigid screw. Exclusion criteria included age <15 years or >45 years, polytrauma, injury to the ankle articular surface, neurological impairment, chronic medical conditions, and other disabilities. Athlete status was assigned based on mention of participation in athletic activity at the high school level or higher in the electronic medical record. The incidence of hardware-associated pain, screw breakage, and screw removal in athletes vs. non- athletes were evaluated using chi-squared and fisher’s exact tests. tests.

Results:

Fifty-five patients met the eligibility criteria. Of these patients, 21 athletes were identified with 34 being non-athletes. In terms of patient characteristics, the athlete group was 90% male, 48% right sided injury, and with an average age of 26.6 (SD 6.8). The non-athlete group was 59% male, 47% right sided injury, and with an average age of 33.6 (SD 6.6). Athletes were observed to have higher incidence of hardware-associated pain (6 (29%) vs. 6 (18%), p=0.341), screw breakage (8 (38%) vs. 8 (24%), p=0.248), and screw removal (19 (90%) vs. 23 (68%), p=0.100) compared to non-athletes in this study. However, only the comparison for screw removal approached statistical significance.

Conclusion:

The results suggest that even in an age matched population, athletes may have higher incidence of screw removal. This study did not have sufficient power to demonstrate a statistical difference in hardware-associated pain or screw breakage, although these did occur at a higher rate in the athlete population. A larger study will be needed to demonstrate statistical significance. Nevertheless, these results suggest that it may make sense to use the suspensory fixation method in athletes in order to avoid a second surgery for hardware removal.
Predictors of early complications following surgical treatment of geriatric ankle fracture
Authors: Choi Seung-Myung , Cho Byung-Ki
Published: September 2017

Category:

Ankle, Diabetes, Trauma

Introduction/Purpose:

Factors predicting complications after surgical treatment of geriatric ankle fractures include presence of various comorbidities such as diabetes, chronic renal disease. However, beyond the binary definition of presence or absence, further speci? c information of these comorbidities such as their chronicity, severity and/or perioperative laboratories have not been studied as risk factors for postoperative complications. The purpose of this study is to investigate the association between the measurements of comorbidities and complications within the? rst 30 days following surgical treatment of geriatric ankle fracture.

Methods:

A retrospective cohort study. From 2000 to 2015, we collected patient demographics, comorbidities-related data including laboratory values and complications within 30 days following open reduction and internal fixation of low energy ankle fractures in patients older than 65 years. Multiple logistic regression analysis was performed to determine factors affecting minor (super? cial wound infection, delayed wound healing, urinary tract infection, pneumonia), major complications (deep wound infection, loss of? xation, deep venous thrombosis, organ/space failure).

Results:

In total, 1,358 patients were included for analysis. The average age was 70.54 years (SD, 7.40). There were 895 (66%) females and 463 (34%) males. Baseline glucose concentrations >200 mg/dL (p < 0.001) and the mean 48 hour postoperative serum glucose concentrations >150 mg/dL (p < 0.001), history of taking wound compromising medications (p = 0.003) were signi? cantly associated with minor complications. Preoperative glycated hemoglobin (HbA1c) >6.5% (p < 0.001), estimated glomerular? ltration rate (eGFR) <45 mL/min/1.73 m2 (p < 0.001), dependent functional status and presence of two or comorbidities (p < 0.001) were statistically associated with major complications.

Conclusion:

poor glycemic control in the perioperative period, wound-compromising medications were associated with increased rates of minor complications, whereas poor chronic glycemic control (HbA1c), decreased renal function and vulnerability with multiple comorbid conditions were associated with major complications. Perioperative blood glucose management may prevent minor complications, whereas and mean serum glucose concentrations of 150 mg/dL and higher during this time period
Comparison between Weight Bearing Radiographs and Weight Bearing ConeBeam CT Examinations in the Assessment of Adult Acquired Flatfoot Deformity
Authors: de Cesar Netto Cesar , Schon Lew , Chinanuvathana Apisan , Lintz Francois , Da Fonseca Lucas Furtado
Published: September 2017

Category:

Hindfoot

Introduction/Purpose:

Adult acquired flatfoot deformity (AAFD) represents a biomechanical derangement involving the three- dimensional (3D) midfoot and hindfoot osseous complex, and can be challenging to optimally characterize using conventional two- dimensional (2D) plain radiographs. Weightbearing (WB) ConeBeam CT (CBCT) can better demonstrate the deformity of the 3D structures during WB. Therefore, we compared validated AAFD measurements between WB conventional radiographs and WB CBCT images.

Methods:

In this prospective, IRB approved and HIPAA compliant study, 20 patients (20 feet, 15 right and 5 left) with clinical diagnosis of flexible AAFD were included, 12 males and 8 females, with a mean age of 52.2 years (range, 20 to 88 years of age), and average BMI of 30.35 kg/m2 (range, 19.00 to 46.09 kg/m2). Involved feet underwent standing (WB) anteroposterior (AP) and lateral radiographs, and were also scanned by WB CBCTs. Both imaging modalities were assessed with traditional AAFD measurements obtained at sagittal (lateral view on radiograph) and axial (anteroposterior view on radiograph) planes using predefined anatomical landmarks, by two independent and blinded foot and ankle fellowship-trained observers. Intra- and Inter- observer reliabilities for both imaging modalities were calculated using Pearson correlation. WB radiograph and WB CBCT measurements were compared by T-Test of the means. P- values < 0.05 were considered significant.

Results:

There was good to excellent intra and inter-observer agreements for most of the measurements on both radiographs and WB CBCT images, with slightly better results favoring WBCT measurements. When comparing WB radiographs and WB CBCT images, we found significant differences in the mean values for some of the measurements, including: talus-first metatarsal angle in the sagittal plane (11.34° x 21.73°, p<0.0001), navicular-medial cuneiform angle (13.19° x 7.63°, p<0.0004), medial cuneiform to floor distance (6.70 mm x 5.50 mm, p<0.0003) and navicular to floor distance (31.34 mm x 23.22 mm, p<0.0001). No significant differences were found when measuring: talus-first metatarsal angle in the axial plane, talar uncoverage angle, cuboid to floor distance and calcaneal inclination angle.

Conclusion:

Traditional adult acquired flatfoot deformity radiographic measurements are obtainable using high resolution 3D WB CBCT imaging. Measurements performed on WB CBCT have similar intra-observer and overall higher inter-observer reliability when compared to WB radiographs. The statistically significant differences found in some of the measurements, when comparing both imaging techniques, might be related to a better characterization of the three-dimensional deformity on WB CBCT images.
20 Degree Post Traumatic Ankle Valgus and Distal Lateral Tibial Osteonecrosis Treated with Staged Deformity Correction and Total Ankle Arthroplasty
Authors: DiDomenico Lawrence , Butto Danielle
Published: September 2017

Category:

Ankle, Ankle Arthritis

Introduction/Purpose:

The purpose of this review is to present a case of post-traumatic ankle valgus and distal lateral tibial osteonecrosis successfully treated with staged deltoid repair, opening wedge tibial osteotomy, fibular lengthening, syndesmotic fusion and total ankle arthroplasty.

Methods:

Initial surgery consisted of ankle joint arthrotomy and deltoid imbrication. The second surgery consisted of a tibial opening wedge osteotomy with autogenous cortical fibular bone graft superior to the area of osteonecrosis to correct the 20 degree ankle valgus. Fibular lengthening osteotomy and fusion of the distal syndesmosis were also performed. CT scan confirmed bony consolidation at the distal tibiofibular syndesmosis as well as union of the allograft opening wedge. The final surgery was total ankle joint replacement with bone grafting of the area of osteonecrosis.

Results:

After 5 years of follow up the patient has progressed out of his AFO to full weightbearing. He reports no ankle pain, improved function and range of motion and is ambulating independently with no assistive devices.

Conclusion:

We successfully treated a case of distal lateral tibial osteonecrosis, and a 20 degree ankle valgus with staged deformity correction and ankle replacement. Radiographs demonstrate a well seated and positioned implant. We believe that with proper alignment that total ankle arthroplasty is a safe treatment option in the face of bone infarction.
The Effect of Orthotics on Ankle and Subtalar Joint Orientation and Load Distribution Utilizing a Novel System to Simulate Weight Bearing in a Cadaveric Model
Authors: Duggal Naven , Nazarian Ara , Nasr Michael , Williamson Patrick , Okajima Stephen , Lechtig Aron , Hanna Philip , Biggane Peter
Published: September 2017

Category:

Ankle, Basic Sciences/Biologics, Hindfoot, Biomechanics

Introduction/Purpose:

Orthotics are commonly prescribed by orthopaedic surgeons to address the hindfoot and midfoot deformity resulting from posterior tibial tendon dysfunction. The public however will often purchase over the counter orthotics for generalized complaints of foot pain that is not associated with any significant deformity or foot pathology. The mechanical axis of the lower limb may be altered in patients who use orthotics despite a normal foot alignment. We hypothesize that patients with normal alignment who use orthotics may adversely change ankle and subtalar joint orientation and load distribution.

Methods:

Five fresh frozen lower limb cadaveric specimens without known skeletal condition were used. The femoral head was potted with PMMA and TekScan pressure sensors were inserted into the ankle and subtalar joint. The specimens were placed on a custom jig, which allowed for load cell modulated loading of the leg; 75 lb load (half body weight) was applied at the femoral head while the foot was supported against a fixed plate keeping the ankle in neutral position. Testing was achieved by placing an orthotic under the medial half of the plantar talonavicular joint level. Mean pressure (MP), peak pressure (PP), contact area (CA), and center of force (COF) were measured in both the ankle and subtalar joints under three conditions; barefoot (BASE), with a 1.5 cm (ORT1) and 3 cm (ORT2) height orthotic. Each condition was tested three times per specimen. Displacement of COF was calculated relative to its location at baseline.

Results:

The MP, PP and CA showed a constant decrease from BASE to ORT1 and ORT2. Despite this relation, the only comparison that was significantly different was that between peak pressure values of the baseline and ORT2 conditions of the subtalar joint. The average displacement of COF from BASE was 0.14 mm and 0.42 mm medially, and 0.26 mm and 0.46 mm posteriorly at the ankle joint with ORT1 and ORT2 respectively. The average displacement of COF from BASE was 0.03 mm laterally and 0.08 mm posteriorly with ORT1, and 0.2 mm medially and 0.46 mm posteriorly with ORT2 at the subtalar joint.

Conclusion:

Foot deformities have an impact on the articular forces in the lower limb. Our results agree with previous studies about the role of foot deformity on the distribution of body weight forces and its consequences across the ankle and subtalar joint. Our novel study also demonstrates that orthotics and orthotics of varying sizes can change the mean pressure, peak pressure, contact area center of force in the ankle and subtalar joint. This study proves the feasibility of its design for studying intra-articular pressure changes in a lower limb cadaveric model with simulated weight bearing.
Outcomes Following Nonoperative Treatment of Isolated Posterior Malleolar Ankle Fractures
Authors: Finney Fred , Kuhn Andrew , Sheibani-Rad Shahin , Charpentier Paul , Holmes James , Bedi Asheesh
Published: September 2017

Category:

Ankle, Trauma

Introduction/Purpose:

Ankle fractures are common injuries, however isolated posterior malleolar fractures are rare. Axial loading of the foot in hyper-plantarflexion is thought to be the most likely mechanism of injury for this fracture pattern. Management of isolated posterior malleolar fractures presents challenges for clinicians, and controversy exists over surgical indications. The literature to-date examining isolated posterior malleolar fractures is scarce and confined to case reports and small clinical series. Recommendations for surgical treatment are based largely on biomechanical studies and not clinical evidence. The purpose of this study was to assess outcomes in a series of patients, who were consecutively treated nonoperatively for isolated posterior malleolus ankle fractures.

Methods:

Outcomes of patients with isolated posterior malleolus fractures who were all treated nonoperatively at two academic teaching hospitals were retrospectively reviewed. The size of the posterior malleolar fracture fragment was measured on lateral ankle radiographs, and clinical outcomes were evaluated using the American Academy of Orthopaedic Surgeons (AAOS) Foot and Ankle Survey. These scores were then compared to published normative data from the general population via independent t-tests. These same outcome measures were then correlated with the size of the posterior malleolar fragment via Spearman Rank Correlations.

Results:

A total of 28 patients (17 male, 11 female) were retrospectively reviewed. The average size of the posterior malleolus fragment was 16.0% (Range: 2.0-59.5%) of the tibial plafond articular surface. The average follow-up duration was 2 years and 7 months. At follow-up, the average “Foot and Ankle Core Score” and “Shoe Comfort Scale Score” were 90 (±11.2) and 80.0 (±28.9), respectively. When these scores were compared to normative data from the general population, no significant differences were found (Foot and Ankle Core Score: p=0.234, Shoe Comfort Scale: p=0.276). There was also no significant association between these scores and the size of fracture fragment. At follow-up, no patients demonstrated signs of instability, dermatological complications, malalignment of the mortise or post-traumatic arthritis.

Conclusion:

This is the largest study to date evaluating outcomes of isolated posterior malleolus fractures in patients treated nonoperatively. This series of 28 patients with isolated posterior malleolar fractures managed nonoperatively demonstrates short- to mid-term functional outcomes that are no different than reported normative data for the general population. These findings are consistent with previously reported clinical outcomes and suggest that nonoperative management is a viable treatment option for isolated posterior malleolar fractures.
The Cavovarus Foot and It’s Association with Fractures of the Fifth Metatarsal
Authors: Fuchs Daniel , Kane Justin , Brodsky James , Royer Christian , Zide Jacob , Reddy Veerabhadra , Bhimani Aamir , Daoud Yahya
Published: September 2017

Category:

Midfoot/Forefoot, Trauma

Introduction/Purpose:

Fifth metatarsal fractures are the most commonly encountered metatarsal fractures. It is often inferred that fifth metatarsal fractures occur at an increased frequency in patients with cavovarus foot position. In particular, zone 2 and zone 3 fractures are thought to be associated with cavovarus feet. However, limited data exists in the literature to support this claim. The hypothesis of this study is that a cavovarus foot alignment is positively correlated with the incidence of fifth metatarsal fractures.

Methods:

298 consecutive fifth metatarsal fractures were compared with a matched control group of 104 patients presenting to an orthopaedic clinic for toe fractures, interdigital neuromas and plantar fasciitis. Radiographic parameters were measured on weight-bearing anteroposterior and lateral x-rays for all patients. An ANOVA test was utilized to compare radiographic parameters between patients with fifth metatarsal fractures and the control group. Parameters that were found to be statistically significant were further analyzed using a Tukey-Kramer test to compare controls and each type of fifth metatarsal fracture (zone 1, zone 2, zone 3, distal oblique diaphyseal, metatarsal neck).

Results:

All radiographic parameters are listed in table 1. A statistically significant difference (p<0.05) for calcaneal pitch, lateral talocalcaneal angle, AP talo-2nd metatarsal angle, talonavicular coverage angle and AP talocalcaneal angle were detected. All parameters are indicative of increased cavovarus in the fifth metatarsal fracture group when compared with controls. In the subgroup analysis, zone 1, zone 2, zone 3 and distal oblique diaphyseal fractures each had a calcaneal pitch, lateral talocalcaneal angle and AP talocalcaneal angle consistent with a more cavovarus position than the control group (p<0.05). Zone 2 and zone 3 fractures had an AP talo-2nd metatarsal angle more consistent with cavovarus than zone 1 fractures and controls. For all other parameters there were no significant differences between each type of fifth metatarsal fracture.

Conclusion:

While it is commonly accepted that cavovarus is a risk factor for fifth metatarsal fractures, there’s little evidence in the literature to support this. This study is the first to show that there is a positive correlation between radiographic parameters that reflect cavovarus foot position and the incidence of fifth metatarsal fractures compared to a matched control group of patients with unrelated pathology. Furthermore, while zone 2 and zone 3 fractures are most commonly thought to be associated with cavovarus, each subcategory of fifth metatarsal fractures in this study had radiographic measurements more consistent with cavovarus foot position than controls.
Particulate Umbilical Cord/Amniotic Membrane for the Treatment of Plantar Fasciitis
Authors: Garras David , Scott Ryan
Published: September 2017

Category:

Hindfoot

Introduction/Purpose:

Plantar fasciitis is the most common cause of heel pain, resulting in an estimated 1 million visits to medical professionals annually. Conservative treatments for plantar fasciitis include rest, orthotics, night splint, stretching and non- steroidal anti-inflammatory drugs. Such treatments are successful in nearly 90% of patients, however, more invasive treatments are required for patients whose heel pain symptoms persist greater than six months. Fetal tissues, including the umbilical cord (UC) and amniotic membrane (AM) have been increasingly used to modulate healing in different parts of the body over the last two decades. These tissues have been demonstrated to possess anti-inflammatory and anti-scarring properties in addition to containing growth factors, cytokines, and matrix components to promote healing, and offer a potential therapy for plantar fasciitis.

Methods:

In this clinical series, we sought to evaluate the efficacy of cryopreserved, particulate UC/AM tissues as a treatment for plantar fasciitis as well as to determine if multiple injections provide an even greater benefit compared to a single injection. A multicenter prospective study was performed where patients were randomized to receive 25, 50, or 100 mg UC/AM tissue and either a single injection or two injections (at baseline and six weeks). All injections were administered under ultrasound guidance into the plantar fascia. At six, 12, and 18 weeks, patients returned and data on foot pain as well as the FAAM questionnaire were collected.

Results:

Last year, we presented interim data on 18 patients who had completed 18 weeks of follow-up. This year, we present the completed results of the study. Overall, patient foot pain was found to be significantly reduced in all treatment groups from baseline. FAAM scores for both activities of daily living and sports subscales also improved in all treatment groups, with overall improvement ranging from 60 – 150% compared to baseline. All patients showed variable degrees of improvement with no patients showing any deterioration.

Conclusion:

The results of this case series are similar to the results of an earlier study which found that injection of a particulate human amniotic membrane product for plantar fasciitis was safe and comparable to corticosteroids. While all treatments demonstrated improvement in both foot pain and FAAM scores, there was both a dose dependent as well as injection dependent effect of particulate UC/AM tissue on foot pain reduction (100 mg > 50 mg >25 mg; 2 injections > 1injection) suggesting a possible additive effect. Overall, these results are promising and highlight the potential effectiveness of UC/AM tissues as a treatment for plantar fasciitis.
Radiographic Results of Intramedullary Nails for Lateral Malleolus Fractures
Authors: Garras David
Published: September 2017

Category:

Ankle, Trauma

Introduction/Purpose:

Plating the lateral malleolus yields predictable patient outcomes and anatomic reductions with an efficient surgical procedure. However, large incisions and prominence result in wound complications in 5% to 16% of patients. Although rudimentary intramedullary fixation has been applied for these fractures for decades, new intramedullary devices have become available with broader indications. These nails have the promise of holding accurate reductions and faster patient rehabilitation with virtually non-existent wound issues due to the minimal incisions required for implantation. The aim of this study was to determine if a new intramedullary nail could provide radiographically sound reductions while reducing wound complications and providing faster rehabilitation in a variety of ankle fracture classifications.

Methods:

We retrospectively reviewed the x-rays of 40 ankle fracture patients repaired by two surgeons at different institutions from March 2015 through October 2016. Patients were followed for a minimum of six weeks. Radiographs were reviewed for fracture healing, mortise alignment and fibular length (figure 1). The group was comprised of usual fracture patterns SER 2, 3,4, PER, uni bimalleolar and trimalleolar. Most reductions were performed percutaneously, however a small-incision was used to reduce older fractures or those that could not be reduced without direct visualization.

Results:

All fractures appeared to have complete union and radiographically anatomic reductions. No wound infections presented, and patients experienced reduced pain with early weight-bearing.

Conclusion:

Modern intramedullary nails can deliver excellent results and provide an important part of a surgeon’s treatment armamentarium for lateral malleolus fractures. The nails are especially valuable for non-compliant patients or those with comorbidities that negatively affect skin healing.
Initial Fibular Displacement as a Predictor of Medial Clear Space Widening in Weber B Ankle Fractures
Authors: Geaney Lauren , Cavanaugh Zachary , Sathe Vinayak
Published: September 2017

Category:

Ankle, Trauma

Introduction/Purpose:

The diagnosis of medial ankle instability in Weber B ankle fractures remains controversial. Manual stress radiographs are considered by many to be the gold standard to assess deltoid ligament integrity (Tornetta 2000). Gravity stress examinations have been shown to be equivalent (Gill 2007, Schock 2007), and also offer the advantage of causing less patient discomfort (Schock 2007). Significant fibular displacement likely serves as a surrogate for the large amount of energy required to tear the deltoid ligament. Therefore, the purpose of this study was to determine the relationship between initial fibular displacement and medial clear space widening on a gravity stress radiograph.

Methods:

A retrospective review was conducted of all patients with isolated Weber B ankle fractures with both initial injury radiographs and gravity stress view from August 1st, 2014 through April 1st, 2016. A total of 17 subjects were identified, age 42.6±17 years, time to GSV 4.6±5 days. On the mortise view of injury radiographs, medial clear space (MCS), superior clear space (SCS), lateral fibular displacement (LFDP) and fibular shortening (FS) were measured, and on the lateral view, anterior to posterior fibular gap (A to P FG) was measured. The gravity stress view was used to measure the medial clear space widening (MCS-W). All statistical analysis was performed using Stata (College Station, TX). T-tests were used to calculate mean and standard deviation of each group, correlation and linear regression analyses were run with each displacement variable relative to MCS-W. ROC analysis was used to determine sensitivity and specificity of the displacement variables.

Results:

Strong significant correlations with MCS-W were found for LFDP (0.69, p=0.003), and A to P FG (0.72, p=0.001), but not with FS (0.34, p=0.18). Linear regression analysis revealed significant ability to predict MCS-W for both LFDP (coefficient=1.12, R2=0.48, p=0.002) and A to P FG (coefficient=2.57, R2=0.52, p=0.001) but not FS (coefficient=0.67, R2=0.11, p=0.18). When LFDP and A to P FG were combined, they accounted for 65% of the variability in MCS-W (coefficient=0.70, 1.76; R2=0.65, p=0.033, p=0.018). ROC analysis for A to P FG using cutoff values of 0.75 mm, 1.0 mm, and 1.25 mm yielded SN and SP of 100% and 75%, 100% and 100%, and 67% and 100%, respectively for each cut point.

Conclusion:

The initial fibular displacement is a strong predictor of medial clear space widening in Weber B ankle fractures. On lateral radiographs, an anterior to posterior fibular gap greater than 1.0 mm showed a sensitivity and specificity of 100% in predicting MCS-W=5.0 mm. This provides another tool to aid clinicians in determining the integrity of the deltoid ligament and may help prevent the need for further patient discomfort with a stress view.
High Variability of Observed Weight Bearing During Standing Foot and Ankle Radiographs
Authors: Ghorbanhoseini Mohammad , Miller Christopher , Kwon John Y. , Walley Kempland , Ghaheri Azadeh
Published: September 2017

Category:

Basic Sciences/Biologics, Trauma

Introduction/Purpose:

Weight bearing radiographs are a critical component of evaluating foot and ankle pathology. An underlying assumption is that patients are placing 50% of their body weight on the affected foot during image acquisition. The accuracy of weight bearing during radiographs is unknown and, presumably, variable, which may result in uncertain ability of the resultant radiographs to accurately portray the pathology of interest.

Methods:

50 subjects were tested. The percent body weight through the foot of interest was measured at the moment of radiographic image acquisition. The subject was then instructed to “bear ½ body weight” prior to the next radiograph. The percent body weight was calculated and compared to ideal 50% weight bearing.

Results:

The mean percent body weight in trial 1 and 2 was 45.7% ± 3.2% (p=0.012 compared to 50% mark) and 49.2% ± 2.4%, respectively (p=0.428 compared to 50%). The mean absolute difference in percent weight bearing compared to 50% in trials 1 and 2 was 9.3% ± 2.25% and 5.75% ± 1.8%, respectively (p=0.005). For trial 1, 18/50 subjects were within the “ideal” (45-55%) range for weight bearing compared to 32/50 on trial 2 (p=0.005). In trial 1 24/50 subjects had “appropriate” (>45%) weight bearing compared to 39/50 on trial 2 (p=0.002).

Conclusion:

There is substantial variability in the weight applied during radiograph acquisition. This study raises significant questions about assumptions we, as orthopaedic surgeons, have made regarding weight bearing radiographs, their reliability and how we should proceed when evaluating them.
Ankle Arthrodesis with Structural Grafts Can Work for the Salvage of Failed Total Ankle Replacement
Authors: Halverson Adam , Berlet Gregory
Published: September 2017

Category:

Ankle, Ankle Arthritis

Introduction/Purpose:

Surgical treatment options after failed total ankle replacement (TAR) are limited to revision total ankle replacements, revision bone block interposition arthrodesis, or amputation. In patients where revision TAR is not an option and limb salvage is desired, conversion to an ankle arthrodesis can provide a stable, plantigrade foot. Revision arthrodesis is challenged by significant bone loss with removal of the TAR implant. The purpose of this study was to report midterm outcomes and radiographic results in a single surgeon’s group of patients who have undergone revision ankle arthrodesis with intramedullary nail fixation and structural allograft augmentation following failed TAR.

Methods:

Institutional review board approval was obtained for this study. A retrospective chart and radiographic review was performed. Patients with a minimum follow-up of 1 year who underwent failed TAR revision with structural femoral head allograft and intramedullary tibiotalocalcaneal (TTC) nail fixation were included. Patients with less than 1-year follow-up and alternative fixation or graft constructs were excluded from the study. Data were collected upon enrollment visit and again at midterm follow-up ranging from 3-7 years post-operatively. Foot Function Index (FFI), American Orthopaedic Foot & Ankle Society (AOFAS) outcomes scores and radiographs were obtained at each visit. Primary outcomes of interest were the rate of limb salvage and patient reported outcome scores. Secondary outcomes include limb length correction and the fate of the structural allograft.

Results:

Five patients were available for enrollment. Average age at surgery was 63.2 (range 56-69) years. Enrollment visits averaged 1.68 years post-operative (range 0.95 - 3.78). Midterm follow-up was at an average of 5.2 years (range 4.7-5.6). Upon enrollment average FFI was 34.82 (range 8.82-75.88) and at midterm follow-up was 20.42 (range 0-35.38). AOFAS scores upon enrollment averaged 66.6 (range 61-77) and at midterm follow-up averaged 70.33 (range 54-88). Radiographic results show union in 4 of 5 patients at enrollment and in 2 of 3 patients upon midterm follow-up. Average limb length discrepancy at enrollment was 1.4 cm (range 0.5 - 2.0) and 1.6 cm (range 0.2 – 2.4) at midterm follow-up.

Conclusion:

Conversion of failed TAR to TTC fusion with femoral head allograft is a salvage technique that can lead to a functional arthrodesis and limb salvage in a situation where options are challenging. Our results show continued improvement in patient reported outcomes scores moving from short-term to midterm follow-up with preservation of limb length and no trend towards structural allograft resorption.