bluuebunny/crossref_metadata_2025 huggingface dataset:
Percutaneous Chevron Osteotomy Combined with Adductor Tendon Release for Hallux Valgus Correction
Authors: Carlucci Sofia , Carrasco Nelly , Santini-Araujo Maria , Parise Ana , Conti Leonardo , Villena Daniel , Dozo Daniel , Sotelano Pablo
Published: October 2019

Category:

Bunion, Midfoot/Forefoot

Introduction/Purpose:

The use of minimally invasive techniques for hallux valgus may provide complete deformity correction with minor soft tissue damage, which reduces morbidity and shortens recovery. In this way, some open osteotomies were adapted to percutaneous approaches, with good outcomes reported. The minimally invasive chevron-Akin (MICA) described by Vernois and Redfern in 2011, combines benefits of percutaneous approaches with a stable internal fixation. Since 2015 we have adapted this technique, by adding a percutaneous adductor tenotomy to dispense with the Akin osteotomy. The aim of this study was to report a single surgeon series of consecutive patients with moderate hallux valgus managed with a minimally invasive chevron osteotomy and a percutaneous adductor tendon release.

Methods:

This was a prospective cohort study. A total of 38 feet with moderate hallux valgus underwent the procedure and were followed up for a minimum 12 months (SD 1.10). The median age was 58 years (IQR 52 - 65), 36 women and 2 men. Radiological parameters were compared at preoperatory and at the last follow-up and included: Hallux Valgus Angle (HVA), Inter- Metatarsal Angle (IMA), Distal Metatarsal Articular Angle (DMAA) and first metatarsal shortening. Time to consolidation was also assessed. For clinical evaluation the American Orthopaedic Foot & Ankle Society score (AOFAS) was evaluated. Complications during the follow up were reported. Patients in which another procedure in the hallux was performed, with previous surgeries or not completed 1 year follow-up were excluded.

Results:

Radiologic postoperative parameters demonstrated to achieved correction. At the last follow up there was a statistically significant decrease in the hallux valgus angle, the intermetatarsal angle and distal metatarsal articular angle. Shortening of the first metatarsus was a mean 7.02 mm (IQR 1.24 - 10,27). The mean AOFAS score increased from 58.23 (SD 9.02) pre-operatively to 97.15 (SD 4.72) post-operatively (p< 0.001). Complications reported were 2 superficial infections, 1 broken screw, 1 screw extraction. Five patients referred metatarsalgia after surgery and 1 presented a fourth metatarsal stress fracture. Only one patient presented lost of correction in the first postoperative week and needed a second surgery.

Conclusion:

Our series of hallux valgus correction with a minimally invasive chevron osteotomy combined with the adductor tendon release shows good clinical and radiological outcomes, and results are comparable to series with the additional Akin osteotomy. Comparative studies are needed for major evidence.
Economic Impact of Comorbidity burden in Total Ankle Arthroplasty and Ankle Arthrodesis
Authors: Chan Jimmy J. , Guzman Javier Z. , Chan Jesse C. , Zubizarreta Nicole , Poeran Jashvant , Vulcano Ettore
Published: October 2019

Category:

Ankle, Ankle Arthritis, Diabetes

Introduction/Purpose:

Demand for total ankle arthroplasty (TAA) and ankle arthrodesis surgery is increasing. Findings from other orthopaedic populations suggest an increasing comorbidity burden among those planned for surgery, however, data on TAA and ankle arthrodesis is lacking.

Methods:

This retrospective cohort study utilized data from the nationwide Premier Healthcare Database (2006-2016) which contains inpatient claims on N=10,085 ankle arthrodesis and N=4,977 TAA procedures. Patients were categorized into Deyo Charlson comorbidity index groups with higher scores representing higher comorbidity burden: 0, 1, 2, =3. Outcomes were cost of hospitalization, length of stay (LOS), total opioid utilization (in oral morphine equivalents), discharge to a skilled nursing facility (SNF) and 30-day readmission. Mixed-effects models estimated associations between Deyo-Charlson comorbidity index and outcomes. We report odds ratios (OR, or % change for continuous outcomes) and 95% confidence intervals (CI).

Results:

In the TAA group, 64.4% of patients were in Deyo-Charlson category 0 while 24.1%, 7.6%, and 3.9% were in the 1, 2, and =3 Deyo-Charlson categories, respectively; this was 50.3%, 23.2%, 12.4% and 14.1% in the ankle arthrodesis group. The most common comorbidities were obesity, diabetes mellitus and chronic pulmonary disease. After adjustment for relevant covariates, patients in the Deyo-Charlson group =3 (compared to ‘0’) were associated with stepwise effects of 77.1% (CI 70.9%;83.6%) longer LOS and 48.5% (CI 44.0%;53.2%) higher cost of hospitalization with higher odds for admission to a SNF (OR=3.12 CI 2.64;3.70), all P<0.0001. Smaller or non-significant effects of comorbidity burden were seen for opioid utilization and 30 day readmission. These effects were also present but less pronounced in TAA patients.

Conclusion:

Comorbidity burden is particularly increasing among patients undergoing ankle arthrodesis where it is associated with significantly increased resource utilization. Our data demonstrate the potential impact of patient selection, which may be crucial in optimizing preoperative status.
Epidemiology of Operative Foot injuries in College Level Athletes
Authors: Chan Jimmy J. , Chen Kevin K. , Guzman Javier Z. , Vulcano Ettore
Published: October 2019

Category:

Hindfoot, Lesser Toes, Midfoot/Forefoot, Sports, Trauma

Introduction/Purpose:

Foot injuries represent a broad category of injuries that may have profound implications in National Collegiate Athletic Association (NCAA) athletes. Accordingly, a more thorough characterization of these injuries and what predisposes NCAA athletes to them is crucial to their prevention. This study examines the incidence and effect of foot injuries on NCAA athletes and their athletic season.

Methods:

Foot injuries across 16 sports among men and women during the 2004-05 to 2013-14 academic years were analyzed from the NCAA Injury Surveillance Program (NCAA-ISP). Three common orthopaedic foot injuries were sub-analyzed, including fifth metatarsal injuries (5MT), Lisfranc injuries, and turf toes. Multiple variables were reported including injury rates per 100,000 athlete-exposures (IR), operative rate, annual injury rate trends, re-injury rates, in-season status (pre/in/post-season) at time of injury, and time loss distributions were compiled and calculated.

Results:

A total of 3718 foot injuries were identified over 10-year period. 4.4% of all injuries were operative. Overall foot injury rate was comparable between male (IR=31.1) and female athletes (IR=32.4); however, the operative injury rate was greater in male compared to female (IR=2.0 vs. 0.6) athletes. The top three operative injuries were 5MT (45.1%), stress fractures (12.2%), and Lisfranc injuries (7.9%). 10.8% of turf toes are re-injury, and average time loss was 7.0 days. 43% of 5MT injuries were operative, and 19.2% were re-injuries. 40.6% of 5MT injuries were season-ending with an average time loss of 36.5 days. 33% of Lisfranc injuries were operative, and 7.5% were re-injuries. 45.9% of Lisfranc injuries were season-ending with an average time loss of 25.9 days.

Conclusion:

Foot injuries are among the most common form of injuries that occur in NCAA athletics. In addition, these injuries can sometimes lead to significant loss of playing time and may even result in the end of the athlete’s season or career. Certain NCAA sports such as men’s football and basketball may more likely predispose patients to season ending injuries and require operative fixation. Close examination of the kinds of foot injuries and their respective mechanisms may help elucidate trends useful in the development of various prevention strategies.
Analysis of Congenital Postaxial Polydactyly of the Foot Using Magnetic Resonance Imagings
Authors: Choi Jun Young
Published: October 2019

Category:

Midfoot/Forefoot

Introduction/Purpose:

We aimed to evaluate the magnetic resonance imaging (MRI) findings of congenital postaxial polydactyly of the foot.

Methods:

Three-hundred and forty-seven feet of 288 patients who underwent congenital postaxial polydactyly or polysyndactyly correction were divided into five subtypes according to the radiographic shapes of deformity origins (widened metatarsal head, bifid, fused duplicated, incompletely duplicated, or completely duplicated). MRIs were assessed to determine whether they unrevealed areas were fused or separated. MRI was also used to assess cases with radiographic phalangeal aplasia.

Results:

Huge variations were noted in MRIs. Fusion or separation at the base or head between original and extra digits were observed, and MRI effectively depicted phalangeal aplastic.

Conclusion:

MRI evaluations of congenital postaxial polydactyly of the foot are useful for determining the anatomical statuses which were not visualized by plain radiography.
Structural Effect of Long-Term Use of Medial Arch Support Insole on Children with Pediatric Flexible Flatfoot
Authors: Choi Jun Young , Kim Min Jin , Suh Jin Soo
Published: October 2019

Category:

Midfoot/Forefoot

Introduction/Purpose:

This prospective study aimed to rule out the effect of the normal physiologic maturation in applying medial arch support insole for patients with pediatric flexible flatfoot (PFFF).

Methods:

From January 2005 to June 2015, 18 patients (34 feet) in group 1 (insole was continuously applied) and 16 patients (32 feet) in group 2 (untreated group) were enrolled. A medial arch support insole was applied from age 10-11 years until radiographic physeal closure.

Results:

In group 1, the talonavicular coverage angle, lateral talo-first metatarsal angle, calcaneal pitch angle, and medial cuneiform height were significantly changed at final follow-up, although all values were still within the abnormal range. Moreover, no significant differences were found in any of the increments of the radiographic parameters between groups 1 and 2.

Conclusion:

Radiographic improvements were found in both medial arch support insole-treated and untreated groups even if all radiographic values were still within the abnormal range. This means that PFFF could be somehow improved with heel stretching exercise until the physes were closed. Further, hindfoot alignment remained unchanged regardless of the medial arch support insole application.
The Long-Term Structural Effect of Orthoses for Pediatric Flexible Flat Foot: A Systematic Review
Authors: Choi Jun Young , Kim Min Jin , Suh Jin Soo
Published: October 2019

Category:

Midfoot/Forefoot

Introduction/Purpose:

Several conservative treatment methods, from intrinsic muscle exercises to orthoses, including insoles or specially designed shoes, have been introduced for pediatric flexible flat foot (PFFF). However, the structural effects of orthoses use remain unclear because the normal physiological maturation of the medial longitudinal arch cannot be ruled out.

Methods:

A comprehensive literature search using five databases, namely MEDLINE, the Cochrane Library, Scopus, the Web of Science, and EMBASE, was performed for pertinent articles published before March 30, 2018. Studies with quantitative data on the effects of the long-term use of orthoses for PFFF were included. The search strategy was adapted as appropriate for all other databases searched considering the differences in indexing terms and search syntax for each database.

Results:

All studies, including randomized controlled trials or prospective cohort studies, could not prove the estimated effects of orthoses on the medial longitudinal arch. However, they revealed that flexible flat feet in young children slowly improved with growth, regardless of the type of footwear used. However, three of four studies, which were case series, revealed that positive long-term effects could be achieved using orthoses.

Conclusion:

There is no strong evidence that the long-term use of orthoses improved the structural problem of PFFF.
Pain and Complications following Bone Marrow Aspirate Concentrate (BMAC) Harvested from the Iliac Crest in Foot and Ankle Surgery
Authors: Christophersen Christy M. , Elattar Osama , Farber Daniel
Published: October 2019

Category:

bone graft in foot and ankle surgery

Introduction/Purpose:

Autologous bone is recognized as the gold standard for bone grafting in orthopedics with the iliac crest being the common harvest site. In an attempt to minimize morbidity associated with structural bone graft harvest from the iliac crest and still maintain the proposed benefit of collecting and transplanting live cells and growth factors, Bone Marrow Aspirate Concentrate (BMAC) obtained from the iliac crest has become increasingly popular. However, any harvest procedure can potentially induce pain and introduce complications. The purpose of this study was to evaluate the safety and complications of BMAC from the anterior iliac crest for use in various foot and ankle fusion procedures.

Methods:

A retrospective chart review was performed on all patients that underwent BMAC harvest from the iliac crest at the time of their foot or ankle surgical procedure by one of four fellowship trained surgeons between 2014 and 2017 with a minimum of six-month follow-up. Patients were evaluated for complications, pain, and functional limitation secondary to the BMAC harvest. The final outcome follow-up for the cohort was conducted using a specifically designed telephone questionnaire to assess patient satisfaction. A total of 55 patients were included, with a median age of 58 years (range 31 to 81 years) and 69% were female.

Results:

Out of the 55 patients, 52 patients (94.5%) reported reported good to excellent results and were satisfied with the procedure at the time the questionnaire was conducted. Only 3 patients reported persistent complications and some element of dissatisfaction with the procedure after 6 months (the minimum follow up), 1 patient reported persistent numbness at the harvest site, and 2 reported some persistent pain at the harvest site lasting up to 6 months. Some patients reported transient complications that eventually resolved with no implication on their satisfaction of the procedure at the time of the telephone questionnaire. Four patients reported hematoma that was treated conservatively and eventually resolved spontaneously. Four patients reported transient numbness at the harvest site with eventual resolution. Immediately post-operatively, 50% of patients reported some element of post-operative pain. However, at the time of the final follow-up (at least 6 months), only 2 patients reported persistent pain at the harvest site lasting up to 6 months, but it was not considered activity-limiting pain.

Conclusion:

BMAC harvest is a safe procedure with a high rate of patient satisfaction and minimal morbidity with mostly self- limiting complications. This is the first study to evaluate the safety of BMAC as a part of foot and ankle surgical procedures.
Association Between Syndesmotic Stability and Fracture Patterns of Lateral Malleolus After Supination-External Rotation-Type Ankle Fractures
Authors: Chun Dong-il , Yi Young , Won Sunghun , Cho Jaeho , Kim Ja-hyung
Published: October 2019

Category:

Ankle, Trauma

Introduction/Purpose:

Syndesmotic injury with supination-external rotation (SER)-type ankle fractures are well known for the serious damages to the osseous and soft tissue envelope. However, the Lauge-Hansen classification system does not provide sufficient information related to syndesmotic injury. In this study, we aimed to investigate factors for preoperative detection of syndesmotic injury according to fracture patterns in SER III and IV ankle fractures by using radiography and computed tomography (CT).

Methods:

All operative SER III and IV ankle fractures treated by a single surgeon from 2009 to 2015 were enrolled in a retrospective database. Based on computed tomographic evidence and intra-operative cotton test, two groups of the ankle factures were divided(stable and unstable). And .2%). Medial space widening and fragment angle of the fibular posterior cortex were measured (Figure1).

Results:

A total of 52 patients with SER III, 75 patients with SER IV, and 27 patients with SER IV equivalent ankle fractures were identified, with 106 in the unstable syndesmosis group (68.8%) and 48 patients in the stable syndesmosis group (31.2%). Medial space widening and fragment angle of the fibular posterior cortex were significant predictors(p<0.01, p<0.01, respectively). The cutoff values of these factors were 4.4 mm and 32.8 degrees, respectively (Figure2).

Conclusion:

In predicting syndesmotic injury at the preoperative period in SER-type III and IV, medial clear space widening and fragment angle of the fibular posterior cortex showed significant correlations. In particular, sharper fragment angle of the posterior cortex indicated higher probability of instability that remained after fracture fixation.
The Influence of Calcaneal and First Ray Osteotomies on the Contact Pressures of the Ankle Joint
Authors: de Cesar Netto Cesar , Zhengyu Gao , Abbasi Pooyan , Smyth Niall , Casscells Nicholas D , Michnick Stuart , Demetracopoulos Constantine , Parks Brent , Miller Stuart
Published: October 2019

Category:

Ankle, Hindfoot

Introduction/Purpose:

Medial displacement calcaneal osteotomies (MDCO) and first ray plantarflexion osteotomies, such as a Cotton osteotomy, are frequently used realignment procedures for hindfoot and ankle joint valgus malalignment. Multiple studies demonstrated the effects of calcaneal osteotomies on the contact pressures of the ankle joint (CPAJ), with slight medial displacement of the center of pressure and lateral unloading of the ankle joint. However, the influence of a first ray plantarflexion osteotomy on the CPAJ is yet to be determined. In this cadaveric study we compared the effects of calcaneal and first ray osteotomies in the CPAJ.

Methods:

Fifteen bellow-knee cadaveric specimens were dissected to expose the ankle joint and isolate the flexor and peroneal tendons. Tekscan 5033 sensors were placed in the ankle joint and held in place with cyanoacrylate. Specimens were loaded in a servohydraulic load frame. The following loads were applied to the tendons: Achilles (200 N), PTT (40 N), peroneals combined (44 N), FHL/FDL combined (35 N). Ankles were tested in an intact position, after isolated MDCO (6, 8, 10 and 12 mm), isolated Cotton osteotomies (4, 8 and 12 mm) as well as combined osteotomies (10 mm and 12 mm, respectively). Specimens were then cyclically load from 100N-700 N at a rate of 0.5 Hz for 30 cycles while CPAJ data was collected at a rate of 20 Hz. Average and maximum pressure data were extracted as well as the center of pressure (CoP) movement in the AP and ML directions.

Results:

There was a significant (p<0.05) and progressive decrease in respective maximum and average contact pressures of the ankle joint when comparing intact ankle (1608 and 1312kPa), calcaneal osteotomy (1291 and 1034 kPa), Cotton osteotomy (1165 and 962 kPa) and combined osteotomies (1134 and 903 kPa). Cotton osteotomy and combined osteotomies showed similar contact pressures. Regarding CoP measurements of the ankle joint, native ankle and MDCO demonstrated similar positionings in the sagittal and coronal planes. Cotton and combined osteotomies caused a significant shift of the CoP anteriorly and laterally when compared respectively to the intact/MDCO and MDCO ankles.

Conclusion:

The results of this study demonstrate that the Cotton osteotomy has a greater effect on the contact pressures of the ankle when compared to the MDCO. There is an overall decrease in the maximum and average pressures as well as a deviation of the center of pressure toward the anterior and lateral aspect of the ankle joint. These findings should guide surgeons when deciding between first ray and calcaneal osteotomies as realignment procedures for hindfoot and ankle valgus deformities.
The Role of Gender and Attire in Patient Perception of Foot and Ankle Physicians
Authors: Farber Daniel C. , Eilberg Brandon , Basatski Aliaksei
Published: October 2019

Category:

Patient Care

Introduction/Purpose:

Initial impressions between physician and patient typically occur through the medium of attire and potentially gender and can significantly impact the comfort and trust of patients in the clinical setting. The influence that foot and ankle orthopaedic physicians have on their patient’s footwear choices is of particular importance because it potentially affects clinical outcomes. Unlike other specialties where physician appearance or gender serves as a basis for mere initial perception, the nature of foot & ankle orthopedics allows for direct influence on a component of their care. The purpose of this study was to examine whether orthopedic physicians may serve as role models for healthy behavior and to elucidate the influence of patient perception on their orthopedic-related decision making.

Methods:

In this prospective, cross-sectional study, individuals =18 years of age that had the ability to make their own footwear decisions were invited to participate. Study subjects completed a 22-question survey following their office visit with one of four foot and ankle surgeons (2 female, 2 male). Quantitative assessment included: demographic data, the level of perception and attention given to their physician’s shoe choices, and various factors that affect decision making process when purchasing orthopedic-related footwear. Chi-square analysis was used to evaluate the categorical variables.

Results:

A total of 250 patients completed the study, with a normal distribution of ages between 18-81. 62% (n=154) had seen their physician multiple times and the remaining were new patients. Female patients preferred using recommendations from same- sex surgeons (41%) much more than males (6%). However, given the option of combining male/female opinions, 45% of females chose that option whereas 72% of males preferred combing male/female physician opinions when deciding on footwear. A sizable minority of patients noticed the type of shoe their physician was wearing that day, 32% (n=81). 52% (n=130) agreed that a surgeon’s own shoe choices should reflect the desirable attributes of a shoe. Patients ranked the shoe feel (51%) and their doctor’s recommendations (28%) as the top factors when deciding shoe-wear.

Conclusion:

Our study indicates that a significant portion of patients are mindful about and do consider their physician’s gender as well as physical appearance including shoe choices. While this influence was greater for females, patient footwear choices are affected across most demographics. The impact of patients’ awareness on medical action indicates that perception of care may hold significant value. Identifying the factors that influence orthopaedic decision-making can aid in accurately targeting patient education, enhancing physician-patient interactions, and improving clinical outcomes.
Radiographic Evaluation of Adult Acquired Flatfoot Correction with Augmented Spring Ligament Repair
Authors: Fogleman Jason , Kreulen Christopher , Sarcon Aida , Michelier Patrick , Swafford Rachel , Giza Eric , Doty Jesse
Published: October 2019

Category:

Flatfoot reconstruction

Introduction/Purpose:

Adult acquired flatfoot often results from posterior tibial tendon dysfunction followed by attenuation of the ligamentous support of the medial longitudinal arch of the foot. The spring ligament is the strongest ligamentous support for the talonavicular joint making it a viable target for flatfoot reconstruction procedures. There are concerns that direct repair of the spring ligament complex could result in failure as the already attenuated tissues of the ligament stretch out with mobilization and weight bearing. Suture tape augmentation of ligament repairs has shown greater loads to failure in biomechanical testing; however, there is a paucity of data surrounding clinical and radiographic outcomes of flatfoot reconstruction with augmented spring ligament repair.

Methods:

A retrospective review was performed of patients who underwent flatfoot reconstruction including spring ligament repair with suture tape augmentation between July 2014 and August 2017. Weight bearing radiographs were obtained for all patients both pre-operatively and at their last available follow-up. All radiographs were assessed by two surgeons for validated radiographic parameters including AP talocalcaneal angle, AP talo-first metatarsal angle, AP talar uncoverage, lateral talocalcaneal angle, lateral talo-first metatarsal (Meary) angle, lateral medial cuneiform-fifth metatarsal height, and lateral calcaneal pitch. Paired sample T-tests were used to compare pre-operative and post-operative radiographic measurements to assess for correction of these parameters.

Results:

57 patients met inclusion criteria. The average time to final radiographic evaluation was 47 weeks (10 to 200 weeks). All radiographic parameters assessed showed significant correction when compared to pre-operative measurements. The average correction for each parameter included 6.02 degrees for AP talocalcaneal angle (p<0.001), 10.96 degrees for AP talo-first metatarsal angle (p<0.001), 12.65% for AP talar uncoverage percentage (p<0.001), 4.27 degrees for lateral talocalcaneal angle (p<0.001), 11.35 degrees for lateral talo-first metatarsal (Meary) angle (p<0.001), 8.31 mm for lateral medial cuneiform-fifth metatarsal height (p<0.001), and 2.91 degrees for lateral calcaneal pitch (p<0.001). Post-operative complications occurred in 5 patients.

Conclusion:

Reconstruction of adult acquired flatfoot with spring ligament repair using suture tape augmentation is a safe procedure that resulted in significant weight bearing radiographic correction at an average of 47 weeks follow-up.
A Clinical Sign for Diagnosis of the Hypermobile First Ray
Authors: Foong Weisheng , Rikhraj Inderjeet Singh
Published: October 2019

Category:

Midfoot/Forefoot

Introduction/Purpose:

The aim of this study is to describe a new clinical sign for diagnosis of hypermobility of the first tarsometatarsal joint (TMTJ). We propose a method of qualifying and quantifying the degree of hypermobility of the first tarsometatarsal joint which is easily reproducible and does not require the use of specific medical devices.

Methods:

23 patients were examined and graded positive for hypermobility of the first ray by a heterogenous group of doctors using this method. This clinical sign of hypermobility of the 1st tarsometatarsal joint is then quantified by measuring the amount of dorsal displacement using a bedside ruler. All patients underwent Lapidus procedure for fusion of the 1st tarsometatarsal joint. Clinical results are documented at 2 years post surgery.

Results:

All 23 patients diagnosed with hypermobility of the first ray had a mean dorsal displacement of 7.95 ± 0.20 mm. Clinical results showed significant improvement in visual analogue scores and AOFAS scores at 2 years.

Conclusion:

Diagnosis of the hypermobility of the first ray can be made clinically using this easily reproducible method. The degree of subluxation of the 1st tarsometatarsal joint can be quantified without the use of cumbersome medical equipment.
An Intra-Operative Assessment of the Axial Rotational Positioning of the Tibial Component Using Patient-Specific Instrumentation Prophecy
Authors: Gagne Oliver J. , Veljkovic Andrea , Townshend Dave , Younger Alastair S.E. , Wing Kevin J. , Penner Murray J.
Published: October 2019

Category:

Ankle, Ankle Arthritis

Introduction/Purpose:

Ankle replacements (TAR) have evolved significantly over the past 10 years. While most TAR systems reference the medial gutter to set axial tibial component rotation, newer CT scan-based patient specific instrumentation (PSI) allows any rotational position to be set, and this is commonly set to bisect the medial and lateral gutter lines. It is still not yet known which alignment technique is optimal.

Methods:

We initiated a prospective cohort analysis of 22 consecutive cases using the Prophecy® 3D PSI guide (Wright Medical Technologies, Memphis, TN). There were four foot and ankle fellowship trained surgeons practicing from two referral centers. Every procedure had an intra-operative photograph taken from the knee looking down to the ankle after both the attachment of the PSI guide to the tibia and the insertion of the standard medial gutter fork. The axial rotational angle between both was measured and compared to the Prophecy® pre-operative plan. Statistical analysis was performed using the student’s T-test for paired distribution and descriptive statistics given the number of cases (N=22).

Results:

The primary outcome of this study was to assess the correlation between the pre-operative medial gutter line drawn on the Prophecy plan and the intra-operative medial gutter fork angle. The Pearson R correlation value was 0.54 (p = 0.53). The average difference between the pre-operative medial gutter line on the Prophecy® plan and the intra-operative gutter fork was -0.46 [95% CI -2.04 – 1.10]. This could mean that the medial gutter fork is on average slightly more internally rotated than templated medial gutter line. However, the average of the absolute differences between the preoperative medial gutter line and the intraoperative medial gutter fork was 2.69 degrees. Of the 22 cases, 11 were within 2 degrees and 17 were within 4 degrees.

Conclusion:

The medial gutter line on Prophecy® PSI pre-operative TAR plans is a moderately good representation of the intra- operative medial gutter fork position used in standard TAR instrumentation. Based on this, using the Prophecy® default which sets the tibial implant axial rotation to bisect the medial and lateral gutter lines will typically lead to greater external rotation of the tibial component compared to standard TAR instrumentation which aligns the tibial component to the medial gutter fork. Further work needs to be done to better understand which of these axial alignment options, or potentially others, is optimal.
Minimal Invasive Mid-Calf Gastrocnemius Recession: Safety and Efficacy Analysis
Authors: Gaitan Laura , Lopez Valeria , Calvi Juan Pablo , Alvarez Victoria , Slullitel Gaston
Published: October 2019

Category:

Midfoot/Forefoot

Introduction/Purpose:

Limited ankle dorsiflexion associated with an isolated gastrocnemius contracture is one of the key impairments present in some chronic foot and ankle pathologies. The Baumann procedure consists of a gastrocnemius recession through an incision along the proximal medial calf performed in the interval between the gastrocnemius and soleus fascia. The advantages of the technique is that isolates the lengthening to the gastrocnemius muscle and preserves muscle strength. It is performed in supine decubitus, making unnecessary to switch position of the patient. We performed it in a minimally invasive fashion through a 4 cm approach. Our purpose was to evaluate the functional results and satisfaction of patients after performing a release of the gastrocnemius through the Baumann minimally invasive procedure in different foot and ankle pathologies.

Methods:

34 patients (37 procedures) whom presented with forefoot or midfoot or rearfoot pathologies that were suspected to be associated with gastrocnemius contracture between 2015 and 2017 were retrospectively evaluated (Table 1). All patient demographic information; such as age, sex, diagnosis and date of surgical, was retrieved from clinical charts. Patients included were to have an isolated gastrocnemius contracture as determined by a positive Silfverskiold test. Patients underwent Bauman gastrocnemius recession alone or in combination with other procedures according to each patient´s primary diagnosis. A supervised physical therapy program that consisted on stretching and flexibility of the posterior chain, was started as soon as possible depending on the underlying pathology, when possible, during the first postoperative week.

Results:

Thirty-seven procedures belonging to thirty-four patients were included in this investigation. The mean age of the patients was 47.13 years (range 26-78 years). The mean follow-up was 21.6 months (range 7-42 months). The average initial amount of ankle dorsiflexion measured was 108 (range 95 to 120) degrees. After gastrocnemius muscle recession, the average ankle dorsiflexion measured was 91 (range 84 to 95) degrees. Therefore, an overall improvement of 17 degrees was obtained. There were significant differences in the dorsiflexion angle measured pre and post-surgery (p < 0.05). 88.9% of the patients were satisfied and would undergo the same surgery if necessary. 91.7% would recommend the procedure to a friend or family member.

Conclusion:

There exists reasonably convincing evidence to support the use of gastrocnemius recession as a therapeutic intervention for isolated foot pain associated with an overload syndrome, justifying a grade of recommendation B. It is our perspective that the Bauman procedure offers a chance to lengthen the musculotendinous unit in a predictable manner, through a small incision avoiding the potential risks of over lengthening the gastrocnemius-soleus complex.
Hindfoot Alignment after Total Ankle Replacement
Authors: Gross Christopher , Manzi Luigi , Indino Cristian , Romano Fausto , Maccario Camilla , Usuelli Federico Giuseppe
Published: October 2019

Category:

Ankle, Ankle Arthritis

Introduction/Purpose:

End-stage ankle arthritis can involve misalignment of the ankle in both the coronal and sagittal planes as up to reported 33% to 44% of patients who present for total ankle replacement have greater than 10° of coronal plane deformity. Normalization of the sagittal and coronal alignment is key in improving survivorship and functional outcomes in TAR. In the present study, we analyzed how both the ankle and hindfoot alignment for both a fixed-bearing and mobile bearing TAR system changes over time. Specifically, we measured coronal and sagittal alignment of both the ankle and hindfoot complex. We hypothesize that both significant differences would be seen between all time points and pre-operative radiographs, and that these differences would not change over time.

Methods:

A retrospective study performed by a single orthopaedic surgeon was performed on two independent groups of patients undergoing two different systems for total ankle replacement: Zimmer TAR (lateral-approach, fixed-bearing, n=89) and Hintegra (anterior approach, mobile-bearing, n=81). We noted specific demographic data and radiographic data were measured including: Hindfoot alignment view angle (HAV), Hindfoot alignment distance (HAVD), tibiotalar ratio, a angle and ß angle. These were measured pre-operatively, and 6 months, 12 months, and 24 months post-operatively. Within-group comparisons were performed using one-way repeated-measures ANOVA (1-w rANOVA), analyzing temporal course of clinical data (comparisons between different time points, e.g. T0vsT6vsT12vsT24) within the Hintegra and Zimmer groups. To compare the time course of clinical measures between the two groups, 2-w rANOVAs were performed for SA, SD, TT ratio, a and ß angle. Specifically, time*group interaction was tested.

Results:

At the ankle joint itself, as measured by the a and ß angles (p>.05), the position of the components remains relatively similar in both the fixed and mobile bearing TAR over the course of 24 months. The sagittal alignment, as measured by the TT ratio, demonstrated a posterior shifting of the talus in the mobile bearing group (p=.036). Though the fixed and mobile-bearing TARhad both significant hindfoot alignment improvement between the pre-op radiographs and twenty-four months, over time, the fixed-bearing ankle had a significant increase in both the HAV and HAVD (p<.001), suggesting a dynamism of the hindfoot in the fixed-bearing ankle.

Conclusion:

Correcting coronal and sagittal alignment is important for the long-term survivorship of a TAR. The fixed and mobile-bearing implants had maintained coronal and sagittal alignment in the short term, the temporal course of the fixed-bearing ankle showed an increased in the valgus positioning of the hindfoot. The mobile-bearing implant maintained its hindfoot alignment over the course of the study. More studies are needed to explore the clinical implications of this new data.
Clinical Evaluation and Management for Lisfranc Injury with Cuneiform Fracture
Authors: Gu Wenqi , Xu Hongwei , Shi Zhongmin , Zhang Hongtao , Mei Guohua , Xue Jianfeng , Zou Jian , Wang Xiaokang
Published: October 2019

Category:

Midfoot/Forefoot

Introduction/Purpose:

To summarize and evaluate the treatment and clinical outcome of Lisfranc injury with cuneiform fracture retrospectively.

Methods:

From January 2014 to December 2017, totally 128 cases of Lisfranc injury with cuneiform fractures were treated in our department including 78 cases of male and 50 cases of female with an average of 42.2 ±10.5 years old . There were 60 left feet and 68 right feet, two of which were suffered from an open injury. From the CT scanning, The avulsion fracture of cuneiform was seen in 48 cases, while other 80 cases were cuneiform body fractures or comminuted fractures. An open reduction and internal fixation were undergone after the improvement of soft tissue condition. Final clinical outcome were evaluated by VAS score and AOFAS midfoot score. Complication were also recorded.

Results:

9 cases suffered from an early stage of wound and soft tissue complication, who were cured by a dressing change. All cases were followed for a mean of 16.3 months (range: 6-36 months). The plain radiograph demonstrated that the bone union were achieved on the 12.8±1.3 weeks (range: 11-16 weeks) post-operatively on average. The VAS score at the final follow-up was 1.8±1.7 (range: 0-8), while the AOFAS midfoot score was 81.3±10.4 (range: 35-95). The excellent and good rate was 88.3%. 12 cases of post-traumatic arthritis of midfoot was manifested on the X-ray, five of which underwent a salvage arthrodesis in consequence of the severe symptom and disability. The implant of 49 cases were removed on an average of 13.5 month (9-24 months).

Conclusion:

The Lisfranc injury is always associated with cuneiform fractures, which should be attached importance to in clinical work. For the simple cuneiform fractures, screw fixation could be performed. The key of management is the restoration of intercunceiform joint. And an anatomical alignment and stable fixation of midfoot may facilitate an acceptable clinical outcome.
Epidemiology of Contact and Non-Contact Ankle Injuries in Collegiate Athletes
Authors: Guzman Javier Z. , Chen Kevin K. , Chan Jimmy J. , Vulcano Ettore
Published: October 2019

Category:

Ankle, Sports

Introduction/Purpose:

Ankle injuries can often have profound implication in the potential careers of National Collegiate Athletic Association (NCAA) athletes. Accordingly, a more thorough characterization of these injuries and insight into injury etiology is warranted. In addition, a more comprehensive understanding will allow proper education of athletes when injuries do occur. Here we review the incidence and effect of ankle injuries on NCAA athletes and their athletic season.

Methods:

Ankle injuries across 16 collegiate sports played by men and women from 2004-05 to 2013-14 academic years were surveyed from the NCAA Injury Surveillance Program (NCAA-ISP). Ankle injury rates per 10,000 athlete-exposures (IR), operative rate, annual injury rate trends, re-injury rates, in-season status (pre/in/post-season) at time of injury, and time loss distributions were perused. In effort to include both male and female atheletes equally, a sub-group analysis of contact sports played by both genders (C-BG) was performed to determine if there was a significant difference in risk when compared to those athletes that did not play contact sports. These sports included basketball, soccer, lacrosse, and ice hockey. Types of ankle injuries (soft tissues or bony) were also sub-classified and counted.

Results:

Over the course of 10 years, there were 14,080 ankle injures identified (IR=11.9). There were 8,978 (IR=12.1) injuries in males and 5,102 (IR=11.7) injuries in females. The rate of injuries that occurred in C-BG cohort (IR=14.5) was greater than that of the total group of noncontact participants (IR=7.6). When comparing injury rates between all contact sports(IR=14.1) and all noncontact sports (IR=7.6) the difference was found to be statistically significant(p <0 .0001). In the C-BG group, 1.4% of injuries were operative (N=93). The overall mean time loss for C-BG was 10.9 days when excluding patients who had season ending injuries. Across all atheletes, the top three contact sports with season ending ankle injuries were football, basketball, and lacrosse. Importantly,16.8% of all injuries were classified as re-injuries.

Conclusion:

Ankle injuries represent a common and broad spectrum of injuries in collegiate athletes. A majority of ankle injuries occurred during the regular season with sprains, strains, contusions, and fractures representing the most common types of injuries. Contact sports tend to have higher rates of ankle injuries than noncontact sports. As the consequence of index ankle injury appears to be higher predisposition to reinjury, a better understanding of the kinds of ankle injuries and their respective causes may help elucidate trends useful in the development of various prevention strategies.
Diagnosing Syndesmotic Instability with Dynamic Ultrasound: Establishing Natural Variations in Normal Motion
Authors: Hagemeijer Noortje , Chang Song Ho , Saengsin Jirawat , Waryasz Gregory , Kerkhoffs Gino , DiGiovanni Christopher , Guss Daniel
Published: October 2019

Category:

Ankle

Introduction/Purpose:

Syndesmotic instability, when subtle, is challenging to diagnose and often requires visualization of the syndesmosis during applied stress. Ultrasound is a dynamic, non-invasive diagnostic tool that can achieve this at the point of care, although accurate assessment requires better understanding of normal physiologic motion. The aim of this study is to assess normal distal tibiofibular motion in the sagittal plane using ultrasound during applied stress.

Methods:

Patients with no history of injury to either ankle were included in this study. The distal tibiofibular joint was examined using an ultrasound probe placed anteriorly with the patient in supine position and posteriorly with the patient in prone position. Sagittal fibular translation was simulated by applying an increasing manual force to the fibula in the sagittal plane: 1) in the supine position, anterior to posterior (SAP), 2) in the prone position, posterior to anterior (PPA), and 3) in the prone position, anterior to posterior (PAP) (Figure 1). The relative position of the fibula and tibia were subsequently measured without force application and then at maximum force application, defined as the end point at which increased force did not result in additional fibular translation. Fibular displacement in cm was thereafter calculated. A linear mixed effect model was built for analysis, wherein subject, examiner, experiment and side were random factors.

Results:

A total of 34 ankles were included. Mean age was 25.0±5 years and 71% were male. After adjusting for gender and side, the model showed that the application of force led to fibular motion in the sagittal plane for each measurement technique. SAP, coef. 0.06 [0.06-0.07], p-value < 0.001. PPA, coef. 0.04 [0.03-0.05], p-value < 0.001. PAP, coef. -0.16 [-0.17- -0.15], p-value < 0.001. The model also showed similar fibular motion values for left and right measurements, SAP p-value 0.589, PPA p-value 0.236, PAP p-value 0.104. Fibular movement values also were not influenced by gender, SAP p-value 0.348, PPA p-value 0.613, PAP p-value 0.714.

Conclusion:

Alterations of syndesmotic motion in the sagittal plane can be successfully identified using dynamic ultrasound under stressed conditions. On average, 0.6 mm of A to P translation and 0.4 mm of P to A translation were found. Equivalent translation values between the left and right side in each patient underscores that, in the injured setting, the contralateral ankle may be used as a reliable control. This establishes a normal value for ultrasound examination of the syndesmosis, allowing future studies examining the injured state.
The Ankle-Hindfoot Kinematics of Current Generation Total Ankle Replacement: A Cadaveric Gait Simulation
Authors: Harnroongroj Thos , Sturnick Daniel , Ellis Scott J. , Demetracopoulos Constantine , Deland Jonathan
Published: October 2019

Category:

Ankle Arthritis

Introduction/Purpose:

Total ankle replacement (TAR) has developed as a standard treatment option for end-stage ankle arthritis with the primary benefit of pain relief and ankle-hindfoot motion preservation. The current generation of TARs features limited bone resection and improved initial fixation of components to restore physiologic constraint and the anatomic articulation of the ankle. However, the ankle-hindfoot kinematics of current TAR designs compared to the baseline native ankle have not yet been extensively studied. Cadaveric gait simulation is a valuable tool for investigating direct effects of surgical procedures on foot and ankle biomechanics. The objective of this study was to assess whether this current generation TAR system could provide normal ankle-hindfoot kinematics as the baseline native ankle using cadaveric gait simulation.

Methods:

Eleven mid-tibia cadaveric specimens were secured to a static mounting fixture with a six-degree of freedom robotic platform to simulate gait in native-intact and TAR conditions. A force plate was moved relative to the stationary specimen through an inverse tibial kinematic path calculated from in vivo data while extrinsic tendons were actuated using physiologic loads (Figure 1A). Ankle-hindfoot kinematics were measured from reflective markers attached to bones via surgical pins. TAR was performed using a current generation, fixed-bearing system by a fellowship-trained foot-ankle surgeon using the manufacturer described protocol (PROPHECY Patient-specific instrumentation, Infinity, Wright Medical Technology). Ankle-hindfoot joint kinematics were measured using the same tibial kinematic inputs and muscle forces as the intact condition. Non-parametric, bias-corrected bootstrapping was used to calculate 95% confidence intervals to compare motion between intact and total ankle replacement.

Results:

Analyses demonstrated no significant difference in average ankle-hindfoot joint kinematics between the intact and TAR conditions (Figure 1B). The result was consistent for the ankle, subtalar, and talonavicular joints, in each plane of motion.

Conclusion:

These findings demonstrate that the current generation of fixed-bearing TAR can recreate normal ankle-hindfoot kinematics patterns seen in normal ankles. Restoring ankle kinematics can be a significant factor in slowing down the progression of adjacent joint arthritis in the foot. However, it is still inconclusive whether ankle-hindfoot kinematics can be restored in patients with long standing ankle arthritis, and this should be addressed in future studies.