bluuebunny/crossref_metadata_2025 huggingface dataset:
The Peroneus Brevis and Plantar Fascia Insertions Are Related to Proximal Fifth Metatarsal Fractures
Authors: Hosseini Ali , Dijk Pim Van , Breuking Sofie , Vopat Bryan , Guss Daniel , Johnson A. Holly , DiGiovanni Christopher
Published: September 2017

Category:

Midfoot/Forefoot

Introduction/Purpose:

Proximal fifth metatarsal fractures (PFMF) are among the most common fractures in the foot and can be categorized into three fracture zones [1]. To investigate the fracture mechanism of PFMF in different zones, a better understanding of the anatomy of the bone and its surrounding soft tissues is required. Both the plantar fascia (PF) and the peroneus brevis (PB) tendon insertions are at the base of the fifth metatarsal, and may contribute to the pathophysiology of PFMF. However, the role of the PB and PF insertions in the pathogenesis of PFMF remains unclear. The purpose of this study was to accurately define the footprint of the PB and PF insertions of the base of the 5th metatarsal in relation to the different zones of PFMF.

Methods:

21 cadaveric fifth metatarsal bones were harvested from cadaveric feet. All bones were freed of any remaining soft tissue adherence, except for the PB and the PF insertions. Three reference screws with a diameter of 1 mm were placed and secured on each bone with 2 screws distally and 1 screw proximally for registration. All bones were CT scanned to create a 3D bone reconstruction. Next, the insertions of the PB and PF and the reference screws of each bone were digitized and then mapped to its corresponding 3D bone model. In order to describe the three different fracture zones of the 5th metatarsal, an established coordinate system was made for each bone to simulate separate fracture zones (Figure a) based on Lawrence guideline [1]. The shape, location and surface areas of both insertions and their relation to the different fractures zones were determined (Figure b).

Results:

The insertion of the PB was oval shaped and located on the dorsal side of the base, with a mean surface area of 88.1 ± 46.4 mm2. The PF was oval shaped and situated around the tip of tuberosity, with a mean surface area of 150.7±53.5 mm2. The PB insertion was present in zone 1 fractures in 100% (21/21) of the 5th metatarsal models and 29% (6/21) of the models for zone 2 fractures. The PF insertion was involved in 100% (21/21) of the 5th metatarsal models for zone 1 fractures and 43% (9/21) of the models for zone 2 fractures.

Conclusion:

Results of this study demonstrate that the insertion of both the PB and PF are involved in all zone 1 PFMF and a significant percentage of zone 2 PFMF. The location of tendon insertions affect the forces exerted on the bone, which may indicate a relation of the insertions of both the PB and the PF with the fracture mechanism of many zone 1 and 2 PFMF. Moreover, in the treatment of these fractures, care should be taken to maintain or restore the anatomy of these insertions to maximize functional outcomes.
ATFL repair alone versus combined repairs of ATFL and CFL
Authors: Hunt Kenneth , Kelley Judas , Fuld Richard , Anderson Nicholas , Baldini Todd
Published: September 2017

Category:

Ankle

Introduction/Purpose:

The standard for lateral ligament stabilization is direct repair of the ATFL by open or arthroscopic technique. The implications and necessity of repairing the CFL are not well understood. The purpose of this study was to assess the impact of repairing the ATFL alone compared to repairing both the ATFL and CFL, in a biomechanical cadaver model. We hypothesized that repairing the CFL will substantially augment ankle and subtalar joint stability during weight-bearing ankle inversion compared to ATFL repair alone.

Methods:

Ten matched pairs of fresh frozen human cadaveric ankles were dissected to expose intact ATFL and CFL. Ankles were mounted to an Instron at 20° plantar flexion and 15° of internal rotation. Each ankle was loaded to body weight and then tested from 0 to 20° of inversion for three cycles; stiffness and torque were recorded, peak pressure and contact area were recorded using a calibrated Tekscan sensor system, and rotational displacement of the talus and calcaneus relative to the ankle mortise was recorded using a three-dimensional motion capture system. Ankles then underwent sectioning of ATFL and CFL and were randomly assigned to ATFL only repair using two arthroscopic Broström all-soft anchors, or combined ATFL and CFL repair. Testing was repeated after repair to 20° of inversion, then load-to-failure (LTF).

Results:

The predominant mode of failure after repair was at the tissue/suture. There were no instances of anchor pullout. There was an 11.7% increase in stiffness in combined repairs, and only a 1.6% increase in ATFL-only repairs. CFL failed at lower torque and rotation than the ATFL in combined repairs. There were strong correlations between intact stiffness and stiffness after repair (r=.74) and ATFL torque in LTF testing (r=.77), across both groups. There was no significant difference in peak pressure or contact area in the tibiotalar joint between the intact ankle and ATFL or combined repair.

Conclusion:

We found a greater increase in stiffness following combined ATFL and CFL repair compared to ATFL repair alone. This added stability is due to complimentary contributions of the CFL, not augmented LTF strength of the ATFL. Intact specimen stiffness correlated strongly with stiffness after repair and LTF torque, suggesting that a patient’s inherent tissue laxity or inelasticity is likely a meaningful predictor of strength after repair. Restoring the CFL plays a relevant role in lateral ligament repair, however sufficient time for ligament healing should be allowed before substantial inversion stresses are applied.
Effectiveness of hyaluronic acid injection after failed arthroscopic microfracture in osteochondral lesion of the talus
Authors: Hwang Yeokgu , Park Yoo Jung , Shim Dong-Woo , Park Kwang Hwan , Han Seung Hwan , Lee Jin Woo
Published: September 2017

Category:

Ankle, Arthroscopy

Introduction/Purpose:

Non-operative treatment options with symptomatic OLT after failed primary arthroscopic treatment may be treated by various methods such as analgesics, anti-inflammatory drug, steroid injection, Platelet rich plasma (PRP) injection and hyaluronic acid (HA) injection. HA injection could be treated OLT besides osteoarthritis on knee or ankle joint. Effect of HA is viscoelastic and lubricating properties primarily, and other biomechanical effect can be considered. Purpose of this study is to evaluate the clinical outcomes of intra-articular HA injection in the patients with recurrent pain after the arthroscopic microfracture for OLT

Methods:

This study included 20 patients who received three weekly injections of intra-articular HA after arthroscopic microfracture for OLT between June 2014 and August 2016. All patients had persistent pain for more than 3 months after the index surgery. The patients were followed for 16.7 months (range: 4.6-30.9). At each visit, the efficacy of HA injection in reducing pain was evaluated by a Visual Analog Scale (VAS). In addition, subjective satisfactions were assessed by the Alexander scale.

Results:

The mean period from the arthroscopic microfracture to the intra-articular HA injection was 26.5 months (range: 6.0- 87.0). Mean VAS scores decreased from 6.7 ± 1.1 at a pre-injection to 3.8 ± 2.3 at post-injection six months (p = 0.02). According to the Alexander scale, there were 65.0% (13/20) good, 25.0% (5/20) fair, and 10.0% (2/20) poor results at post-injection six months. There was no severe adverse effect.

Conclusion:

The HA injection may be a useful treatment option after failed arthroscopic microfracture in OLT. Further studies will be needed to evaluate long-term results.
Functional Outcomes of Peroneal Reconstruction with Peroneal Tendon Transfer
Authors: Jaffe David , Vier David , Kane Justin , Brodsky James
Published: September 2017

Category:

Hindfoot

Introduction/Purpose:

Tears of the peroneal tendons are a frequent cause of pain and disability. Surgical intervention is frequently warranted for symptoms that persist despite conservative management. Surgical treatment can include repair, local tendon transfers (i.e. peroneus longus to brevis transfer), or allograft reconstruction. While allograft reconstruction has been advocated for reconstruction of even a single peroneal tear, the indications are not widely agreed upon. The hypothesis of this study was that reconstruction with excision of the diseased tendon and transfer to the adjacent peroneal tendon produces significant improvements in both pain and function.

Methods:

Patients that underwent surgical intervention for peroneal tendon pathology at a single institution by a fellowship- trained foot and ankle orthopaedic surgeon were prospectively followed. Operative reports were reviewed to identify patients that underwent peroneal reconstruction with excision of the diseased tendon and local tendon transfer for chronic, severe peroneal tearing. Preoperative AOFAS and Visual Analog Scores (VAS) were obtained as a baseline and then repeated at one year following surgery. Statistical analysis was performed to compare preoperative and postoperative pain and function.

Results:

14 patients were identified that underwent peroneal reconstruction without allograft tendon using reconstruction with excision of the diseased tendon and transfer to the adjacent peroneal tendon. Average age was 41.2 years (range 23-61 years) and average follow-up was 26.7 months (range 12-67 months). At one year, patients’ AOFAS scores improved from 51.9 +/- 12.2 to 90.7 +/- 3.4 (p<0.0001). VAS scores decreased from 6.5 +/- 1.2 to 1.6 +/- 0.9 (p<0.0001). There was 100% survivorship of the reconstruction procedure at one year. One patient underwent an allograft reconstruction for recurrent tearing five years after initial surgery and no other patients underwent a revision procedure. Demographic data and functional scores before and after surgery are displayed in Table 1.

Conclusion:

Peroneal reconstruction performed via excision of the torn tendon and local transfer to the adjacent tendon results in clinically significant improvement in pain and function without the need for allograft tissue. Patients may be counselled that peroneal transfer for chronic, severe tears leads to significant improvement and excellent clinical outcomes. This study shows excellent results can be obtained with local tendon transfer and the authors advocate this procedure to avoid the cost and risk of allograft transplant.
Comparison between Absorbable and Nonabsorbable Suture Material in Modified Broström Operation
Authors: Kang Chan , Kang Donghun , Song Jaehwang , Noh Chang-Kyun , Ahn Ki-Jun , Lee Gi-Soo
Published: September 2017

Category:

Ankle, Trauma

Introduction/Purpose:

The current clinical standard for the surgical treatment of lateral ankle instability remains the modified Broström procedure. Almost surgeons are using non-absorbable suture material because of their strength & permanent. But this has several complications such as irritation, surface tenderness, etc. So we compare the clinical result between nonabsorbable and absorbable suture material.

Methods:

All patients who underwent the modified Broström operation of the anterior talofibular ligament and/or the calcaneofibular ligament by a single surgeon between July 2011 and May 2015 were included in this study. A total of 96 patients were included in this study: 63 men and 33 women (mean age, 33.16 years; range, 14-72 years). Non-absorbable suture(2-0 Fiberwire®, Arthrex, Naples, FL) patient were 50 (33 men, 17 women) and absorbable suture(0-Vicryl®, Ethicon, Sommerville, NJ) patient were 46(30 men, 16 women). Mean follow-up duration was 2.5 years (range, 1.0-4.7 years). Patients completed a subjective questionnaire. Outcomes measures included the Foot and Ankle Disability Index (FADI), American Orthopaedic Foot and Ankle Society (AOFAS) and Reoperation cases by the recurred lateral ankle instability. All data were collected prospectively and reviewed retrospectively.

Results:

In non-absorbable suture group, The mean talar tilt angle in preoperative talar tilt test was 14.4 and in absorbable suture group, 13.7, respectively. The mean talar tilt angle in postoperative talar tilt test was 5.3 and in absorbable suture group, 6.1, respectively. There were no significant differences between non-absorbable suture method and absorbable suture method with talar tilt angle in varus stress x-ray (P > .05). There was no significant difference in FADI (87 vs 91; P = .553), AOFAS (83 vs 87; P = .372) score between non-absorable suture method group and the absorbable suture method group. During follow up, Except of 2 patients, they were no clinical symptom. Each one patient in non-absorbable and absorbable suture group underwent revision lateral ligament surgery.

Conclusion:

As compared with non-absorbable suture in open modified Broström procedure, absorbable suture method produced similarly favorable outcomes.
Comparison Between With Kirschner-wires Only And Combined Screw Fixation in Proximal Reverse Chevron osteotomy(PCMO) For Hallux Valgus Deformity
Authors: Kang Hwa Jun , Jung Hong-Geun , Lee Jong-Soo , Kim Sungwook , Sun Mao Yuan
Published: September 2017

Category:

Bunion

Introduction/Purpose:

Kirschner-wires fixation, sometimes we have encountered pin irritation or pull-out. This is the reason why we consider additional fixation. Moreover, there are few reports according to comparison of fixation method, and Most of them focused on comparison K-wires or screw fixation only. Purpose of study is to compare clinical and radiographic outcome between Kirschner-wires only and combined screw fixation.

Methods:

The study included two different groups according to fixation methods. One with Kirschner-wires fixation (KW group) included 117 feet(of 98 patients), the other with combined screw fixation (KWS group) 56 feet (of 40 patients) with moderate to severe hallux valgus. Clinically, the preoperative and final follow-up visual analog scale (VAS) pain scores, the preoperative and final follow-up American Orthopaedic Foot & Ankle Society (AOFAS) hallux metatarsophalangeal (MTP)-interphalangeal (IP) scores, and patient satisfaction after the surgery were evaluated. Radiographically, the hallux valgus angle (HVA), intermetatarsal angle (IMA), medial sesamoid position (MSP), and first to fifth metatarsal width (1-5MTW) were analyzed before and after surgery.

Results:

The mean AOFAS score improved preoperative 65.5 to 95.3 at final follow up in group A, while preoperative 56.5 to 88.6 at final follow up. Pain VAS decreased from 5.7 to 0.5 in group A, whereas from 6.2 to 1.6 in group B. The mean HVA all improved from preoperative 38.5 to 9.3 at final follow up in group A and 34.7 to 9.1 in group B. The mean IMA and MSP also improved significantly at final follow up. In comparative analysis, the IMA did not show significant difference between postoperative and final state in group A, while showed significant increase in group B.

Conclusion:

We achieved favorable clinical and radiographic outcomes with minimal complications in patient with moderate to severe hallux valgus in both groups. However, this study shows no statistically significant difference in IMA during follow-up period and lower recurrence rate. Therefore we need to consider combined fixation method to provide better stability and can expect lower recurrence rate.
Joint space widening may be a paradoxical pathologic feature of early ankle arthritis
Authors: Kim Ji-Beom , Lee Woo-Chun , Yi Young , Choi Seung-Myung
Published: September 2017

Category:

Ankle, Ankle Arthritis

Introduction/Purpose:

Joint space narrowing and bony spur are typical pathologic feature of early ankle osteoarthritis. The meaning of joint space widening has never been discussed in previous literature. However, we found some osteoarthritic ankles which showed joint widening with diffuse spur change.(Fig.1) We hypothesized that joint space widening may be caused by malpositioning of the talus which may lead to degenerative arthritis. The purpose of this study were to investigate the radiological abnormalities in ankles with joint space widening.

Methods:

In order to define joint space widening and anterior subluxation of the talus, we included 72 ankles (66 people) with no abnormalities on plain radiographs into control group. We measured joint space and lateral talar station(LTS) on plain weight- bearing radiographs.(Fig.2) The 95% prediction interval of joint space (2.4 mm to 4.2 mm) and the LTS (-0.9 mm to 3.8 mm) in the control group were regarded as a normal range. The joint space widening was defined when the joint space was wider than 4.2 mm, and the anterior subluxation of talus was defined when the LTS was larger than 3.8 mm. Thirty-two ankles (29 people) with the joint space widening which underwent operation in our clinic between 2009 and 2014 were included in patient group. Ankle instability was determined on stress radiographs (Fig.2). In the patient group, we investigated the anterior subluxation of talus and the ankle instability, and the sites of spur in conventional CT.

Results:

The average age was 26 years (range:18 - 35) in the control group and 33 years (range:16 - 71) in the patient group. The mean joint space of the patient group was 4.7 mm (range: 4.3 mm to 6.0 mm). In the patient group, the LTS showed a mean of 6.4 mm (range 3.9 mm -10.7 mm). Because all the LTS in the patient group was over the 3.8 mm, the anterior subluxation of talus was showed in all ankles of the patient group. In the patient group, 31 ankles (97%) showed instability on anterior stress radiograph and 24 ankles (75%) showed instability on varus stress radiograph. All ankles in the patient group showed spurs on 4 sides of ankle, anterior, posterior, medial and lateral side.

Conclusion:

This study showed that paradoxical joint space widening may be a pathologic feature of early ankle arthritis which had diffuse spur change, anterior displacement of the talus and ankle instability.
Plantar Fascia Release Through a Single Lateral Incision
Authors: Kiskaddon Eric , Meeks Brett , Laughlin Richard , Roberts Joseph
Published: September 2017

Category:

Hindfoot, Midfoot/Forefoot, Cadaver Study

Introduction/Purpose:

Plantar fascia release (PFR) and calcaneal slide osteotomy (CSO) are often components of surgical management for cavus deformities of the foot. In this setting, the PFR has traditionally been performed through an incision over the medial calcaneal tuberosity, while the CSO is performed through a lateral incision. Two separate incisions can potentially increase surgical morbidity. We hypothesized that the plantar fascia could be fully released from the same lateral based incision that is used for the CSO, obviating the need for a medial incision.

Methods:

Six cadaver feet were dissected. A medial sided dissection was performed to isolate the tibial, medial plantar, lateral plantar, and calcaneal nerves, and the origin of the plantar fascia. Next, an incision was made on the lateral aspect of the ankle inferior and parallel to the peroneus longus tendon. Dissection was carried to bone. A curved face osteotome was utilized to sweep the plantar fascia off the calcaneus just distal to its proximal insertion. A #10 scalpel was inserted into this space, parallel to the plantar fascia and was directed towards the plantar fascia insertion; it was then turned ninety degrees so that the blade was perpendicular to the plantar fascia. The ankle was dorsiflexed until a full release was achieved. A Stryker oscillating saw was used to create a CSO through the lateral incision. We then inspected the medial structures in their relationship to the PFR and CSO.

Results:

In all six cadavers, the plantar fascia was fully released from its origin at the medial calcaneal tuberosity through the lateral incision. There was no obvious damage to the medial and lateral plantar nerves with this lateral based PFR. The CSO made through the lateral incision reliably crossed the calcaneal branch of the tibial nerve in all specimens and the osteotomy was posterior to the lateral and medial branches of the tibial nerve.

Conclusion:

PFR through a lateral incision is a safe and reliable method as part of the surgical treatment for cavus deformities of the foot. We achieved a full PFR in each cadaver specimen. An added benefit is that PFR through a lateral incision avoids the morbidity of an additional surgical incision. Further, a calcaneal slide osteotomy performed through a lateral based incision reliably crosses the calcaneal branch of the tibial nerve. Both PFR and CSO can be safely performed through a lateral incision; however, care must be taken when completing the CSO to ensure that the medial neurovascular structures remain uninjured.
Subtalar Joint Alignment in Ankle Osteoarthritis
Authors: Krähenbühl Nicola , Zwicky Lukas , Deforth Manja , Hintermann Beat , Knupp Markus
Published: September 2017

Category:

Ankle Arthritis, Hindfoot

Introduction/Purpose:

The influence of the subtalar joint on the evolution of ankle joint osteoarthritis is still a matter of debate. Although subtalar joint compensation of deformities above the ankle joint was proposed until mid-stage of ankle osteoarthritis, the evidence of this assumption is weak. In this study, we investigated the subtalar joint alignment in different stages of ankle joint osteoarthritis using weightbearing CT scans. The influence of the tibio-talar tilt and presence of subtalar joint osteoarthritis was additionally assessed. We hypothesized, that the subtalar joint compensates for deformities above the ankle joint in early- to mid-stage of ankle osteoarthritis. We also hypothesized, that subtalar joint compensation increases with a pronounced tibio-talar tilt and decreases with the presence of subtalar joint osteoarthritis.

Methods:

We included patients with ankle joint osteoarthritis treated in our institution from January 2013 to April 2016. A control group of 28 patients was additionally assessed. Varus and valgus ankles were subdivided according to the modified Takakura classification, the tilt of the talus in the ankle mortise and stage of subtalar joint osteoarthritis. The type of ankle osteoarthritis was diagnosed on a plain weightbearing anterior to posterior radiograph of the ankle. The medial distal tibial angle (TAS) and the angle between the tibial shaft and the surface of the talar dome (TTS) were measured. The subtalar joint alignment was assessed using weightbearing CT scans. Two angles were assessed: The subtalar inclination angle (SIA) was measured to investigate the subtalar compensation. For assessment of the morphology of the talus, the inftal-subtal angle (ISA) was determined.

Results:

This analysis showed significant differences of the subtalar inclination between varus feet and the controls (SIA, P=.001). Regarding the talar morphology, significant differences were found between varus/ valgus feet and the controls (ISA, P=.001 and .036, respectively). No significant differences of the subtalar joint inclination and talar morphology could be identified comparing different stages of ankle joint osteoarthritis inside the varus or valgus group. No relationship between the tilt of the talus in the ankle joint mortise and the subtalar joint inclination or talar morphology was identified. Neither presence nor absence of subtalar joint osteoarthritis influenced the subtalar joint inclination and talar morphology.

Conclusion:

Varus ankles compensate in the subtalar joint for deformities above the ankle joint. Compensation had no influence on the stage of ankle osteoarthritis, extent of the tibio-talar tilt and stage of subtalar joint osteoarthritis. Consequently, the progression of ankle joint osteoarthritis is more depended on the supramalleolar alignment and integrity of the periarticular structures (i.e. ligaments and tendons) than on the osseous alignment of the subtalar joint.
Treatment of Moderate Hallux Valgus by Percutaneous, Extra-articular Reverse-l Chevron (PERC) Osteotomy
Authors: Lucas Julien , Laffenetre Olivier
Published: September 2017

Category:

Midfoot/Forefoot

Introduction/Purpose:

The purpose of this study was to report a single surgeon series of consecutive patients with moderate hallux valgus managed with a Percutaneous Extra-articular Reverse-L Chevron (PERC) osteotomy.

Methods:

A total of 38 patients underwent 45 PERC procedures. A medial approach is used just proximal to the flare of the metatarsal head. The osteotomy is performed using a burr, the thickness of which is selected according to the planned correction and shortening. A second dorsolateral approach is then performed and the osteotomy is fixed using a self-drilling, self-tapping 3 mm diameter cannulated and headless compression screw. There were 35 women and three men. The mean age of the patients was 48 years (17 to 69). An additional percutaneous Akin osteotomy was performed in 37 feet and percutaneous lateral capsular release was performed in 22 feet. Clinical and radiological assessments included the type of forefoot, range of movement, the American Orthopedic Foot and Ankle (AOFAS) score, a subjective rating and radiological parameters. The mean follow-up was 59.1 months (45.9 to 75.2). No patients were lost to follow-up.

Results:

The mean AOFAS score increased from 62.5 (30 to 80) pre-operatively to 97.1 (75 to 100) post-operatively. A total of 37 patients (97%) were satisfied. At the last follow up there was a statistically significant decrease in the hallux valgus angle, the intermetatarsal angle and the proximal articular set angle. The range of movement of the first metatarsophalangeal joint improved significantly. There was more improvement in the range of movement in patients who had fixation of the osteotomy of the proximal phalanx.

Conclusion:

Preliminary results of this percutaneous approach are promising. This technique is reliable and reproducible. The PERC osteotomy procedure is an effective approach for surgical management of moderate hallux valgus which combines the benefits of percutaneous surgery with the versatility of the chevron osteotomy. Its main asset is that it maintains an excellent range of movement; other advantages relate to the procedure being performed on an outpatient basis and the absence of tourniquet use.
Age-Related Outcome of Mobile-Bearing Total Ankle Replacement
Authors: Maccario Camilla , Vulcano Ettore , Indino Cristian , Manzi Luigi , Usuelli Federico Giuseppe
Published: September 2017

Category:

Ankle, Ankle Arthritis

Introduction/Purpose:

Total ankle replacement (TAR) is becoming increasingly popular amongst patients with end-stage ankle arthritis. This is in part related to the advances in design, technology, and technique that have improved TAR longevity. The ideal candidate for a TAR is not fully clear. For a long time patients over age 50 years, body mass index (BMI) under 30 kg/m2, and with low functional demands represented selection criteria for many patients. However, these criteria were based off a very limited number of scientific studies on older TAR designs. The aim of this study is to investigate clinical and radiographic outcome in patients of 50 years or less versus patients over 50 years undergoing a Hintegra® total ankle replacement (Integra, Plainsboro, NJ).

Methods:

This study includes 70 consecutive patients who underwent primary TAR from May 2011 to April 2014. The cohort was divided into 2 groups: the young group (YG) with age less than or equal to 50 years, and the older group (OG) with age above 50 years. Patients were assessed clinically and radiologically preoperatively and at 6, 12 and 24 months postoperatively.

Results:

A significant increase in the AOFAS and SF-12 and decrease in VAS scores was seen in both groups between preoperative and final followup (p < 0.001). There was a statistically significant difference between the YG and OG for the AOFAS score at final follow-up. The YG had significantly greater improvement compared to the OG (p = 0.046). In addition radiographic results showed no statistically significant difference in the coronal and sagittal alignment between the 2 groups. The mean postoperative angles in either study group demonstrated significant improvements compared to the preoperative alignment.

Conclusion:

This study demonstrates that total ankle arthroplasty is an effective short-term treatment for young, active patients with symptomatic end-stage ankle arthritis. Our findings are in disagreement with the widespread theory that ankle replacement is a more reliable treatment in the elderly
Reading the Future
Authors: MacDonald Ashlee , Houck Jeff , Baumhauer Judith
Published: September 2017

Category:

Bunion, Midfoot/Forefoot

Introduction/Purpose:

Hallux valgus is a common condition of the foot with 4.4 million patients seeking care yearly for this condition. A previous study suggested specific pre-operative cut-off scores based on Patient Reported Outcomes Measurement Information System (PROMIS) physical function (PF), pain interference (PI), and depression (D) values could predict post-operative outcomes in foot and ankle surgery. Though hallux valgus correction, among other procedures, were identified as one of the most common surgeries in the previous study, specific conditions were not considered separately. The purpose of this study was to evaluate the validity of applying a published comprehensive pre-surgical PROMIS profile of PF, PI and D to patients undergoing bunionectomy surgery.

Methods:

PROMIS scores were prospectively obtained from patients evaluated in a specialty foot and ankle clinic between February 2015 and November 2016. Using ICD-9/10 and CPT codes, a total of 65 patients with hallux valgus who underwent a bunionectomy by a single surgeon were identified. Those with less than two-month follow-up, multiple procedures during the follow-up period, and incomplete PROMIS assessment scores were excluded, resulting in 42 patients. Using pre-operative scores and scores at the last follow-up visit, minimally clinically important differences (MCID), receiver operating characteristic (ROC) curves, and area under the curve (AUC) were obtained to determine if pre-operative PROMIS scores predicted achieving MCID with 95% specificity or failing to achieve a MCID with 95% sensitivity. New cut-off values were then compared to the previous study.

Results:

The AUC for PF (p=0.01) and Mood (p=0.03) were significant. However, PI AUC was not significant (p=0.14). The PF cut off for 95% specificity of exceeding MCID was 39.6 and 50.2 for 95% sensitivity for failing to achieve MCID. The D cut off for 95% specificity of exceeding MCID was 39.4 and 58.1 for 95% sensitivity for failing to achieve MCID. Patients below the 50.2 threshold (n=27) had significantly greater improvements on PF (2.3 95% CI 0.5 to 4.3) and PI (-3.8 95% CI -6.9 to -0.7) but not D. Patients above the 50.2 cut off (n=15) were significantly worse on PF (-7.3 95% CI -12.0 to -2.7) at this short follow up and were statistically unchanged on PI and D.

Conclusion:

This data confirms that pre-surgical PROMIS PF and Depression scores are significant post-surgical predictors. However, cut-off scores for 95% sensitivity/specificity were one standard deviation higher for PROMIS PF (>50.2 versus previous study >42) and similar for Depression (<39.4 versus previous study <41.5) as compared to all foot and ankle surgeries. Patients meeting the new cut-off (>50.2) experienced significantly better outcomes on all PROMIS scales and patients not meeting the cut- off (~30%) were significantly worse. Although longer term follow-up is desirable, this short term follow up suggests a significant clinical impact of using PROMIS scores for pre-surgical decisions.
Functional Outcomes of Revision Total Ankle Arthroplasty
Authors: Michnick Stuart , Brage Michael , Lauder Alexander
Published: September 2017

Category:

Ankle, Ankle Arthritis

Introduction/Purpose:

Ankle arthritis treatment options have advanced over the recent years to include total ankle arthroplasty (TAA). There are known long term consequences of ankle arthroplasty such as aseptic loosening and infection. As the popularity of ankle arthroplasty increases, the need for revision total ankle arthroplasty is also increasing. There is a paucity of reported functional outcomes for revision ankle arthroplasty in the literature. This study aims to assess the functional outcomes following revision TAA and compare these with functional outcomes for patients following primary TAA. Our hypothesis is that patients with revision TAA will perform more poorly on functional tests than patients with a primary TAA.

Methods:

This is a non-randomized prospective and retrospective review. All patients who underwent revision TAA with a modern implant at our institution were included in a retrospective cohort analysis. Additionally, patients who underwent primary TAA with a modern implant were also included as a separate group. Included patients had complete records following TAA with a minimum of one-year follow-up from the time of surgery. Functional outcomes were measured in terms of patient self-reported questionnaires administered via mail survey. Short Form 36 (SF-36) and Foot and Ankle Ability Measure (FAAM) scores were utilized to assess patient functional outcomes. Data was analyzed using a Mann-Whitney U test and an independent-t test to determine if there was a significant difference between each study population. A total of 44 patients who underwent a revision TAA were identified and 24 returned surveys. 89 men and women were identified and 43 returned a survey.

Results:

When evaluating SF-36 survey results between primary and revision TAA, a statistically significant correlation was found in the physical functioning (p<0.01), physical role functioning (p=0.01), vitality (p=0.02), social functioning (p=0.04) and bodily pain (p<0.01) categories. The revision TAA patients scored worse in each category. Additionally, FAAM results in both the activities of daily living and sport categories (p<0.01) yielded a significant correlation with the primary TAA patients scoring better.

Conclusion:

In our study, patients performed better after a primary TAA with better SF-36 scores in multiple categories, especially categories which tested the patient’s perception of their physical health. Additionally, patients performed better in both FAAM categories after a primary total ankle arthroplasty. Overall, patients functioned more poorly in physical activities and vitality after a revision TAA compared to a primary TAA. They were not affected as much from an emotional standpoint. This data can help educate prospective patients on what to expect after a revision arthroplasty when compared to their already completed primary TAA.
Does it Need Operation in Pediatric Triplane Fracture?
Authors: Park Chul-Hyun , Choi Hongjoon , Chun Dong-Il , Cho Jaeho , Park Jaewoo
Published: September 2017

Category:

Ankle, Trauma

Introduction/Purpose:

The proper treatment of triplane fractures is still controversial. The purpose of this study was to compare the clinical and radiographic outcomes of nonoperative and operative treatments of triplane fractures and to clarify whether operative treatment is always necessary for triplane fractures with displacements of >2 mm.

Methods:

Thirty-three patients who were diagnosed as having triplane fractures between January 2007 and January 2014 were reviewed. The first 19 consecutive patients were treated conservatively with closed reduction regardless of age, sex, and fracture severity (nonoperative group), and the latter 14 patients were treated surgically (operative group). Clinical results were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) scale and modified Weber protocol (MWP) scores. Bone union, plafond varus and valgus, presence of, leg-length discrepancy (LLD), premature closure of the growth plate, and posttraumatic arthritis were radiographically examined.

Results:

The mean AOFAS score was 100 for the nonoperative group and 98.1 for the operative group, showing no statistically significant difference between the groups (P = 0.304). The MWP scores were excellent in both groups. One patient in each group showed a LLD of >10 mm at the last follow-up. None of the patients had nonunion, plafond deformity, premature closure of the growth plate, and posttraumatic arthritis.

Conclusion:

Nonoperative treatment of triplane fracture is comparable with operative treatment in terms of clinical and radiographic results. Therefore, we suggest that nonoperative treatment may be a better option than operative treatment for triplane fracture, considering the risk of psychiatric trauma from surgery and the necessity of implant removal.
Minimally Invasive Fasciotomy for Chronic Exercise-Induced Compartment Syndrome
Authors: Pellegrini Manuel , Carcuro Giovanni , Muñoz Gerardo , Somarriva Marcelo , Cuchacovic Natalio , Birman Eddie , Muñoz Francisco
Published: September 2017

Category:

Sports

Introduction/Purpose:

Chronic? exercise-induced compartment syndrome (CEICS) is a commonly misdiagnosed source of pain. Although CEICS is seen infrequently in the general population, its incidence in high-performance athletes is estimated to be 0.49 per 1000 per year. Delayed diagnosis should be avoided, as irreversible sequelae can result, often causing sports retirement. We present our experience in diagnosis and treatment of CEICS.

Methods:

After IRB approval, we conducted a retrospective patient chart review. Patients were included if they were older than 18 years, experienced leg pain after 30 minutes of intense exercise, had a normal-appearing leg MRI, and failed conservative therapy for a minimum of six-months. Patients were excluded if they were diabetic or neuropathic. Significant increments in post-exercise compartment pressure were demonstrated in all patients using Whitesides’ measurement technique. All patients were operated on with minimally invasive fasciotomy and followed for a minimum of 6 months. Complications, functional outcomes (FAAM, FAOS & LEFS), and return-to-sports time were documented.

Results:

Seven male patients met inclusion criteria, with a mean age of 29 years (20-45). Four patients presented pain in the left leg, and three patients were symptomatic in both the right and left legs. All patients had an incremented pressure differential in the anterior compartment, while two exhibited a concomitant pressure increment in the lateral compartment. Postoperatively there was a significant subjective improvement in pain, functionality, and sports performance. High functional scores (FAAM x=92.4, FAOS x=90.3, and LEFS x=72) were documented at 6 months follow-up. Patients returned to sports at an average of 15 weeks and resumed a pre-surgery sports level at an average of 24 weeks. No complications were observed.

Conclusion:

Our results suggest that CEICS can be approached safely through a minimally invasive fasciotomy, with satisfactory functional outcomes and return to sports in the short term follow-up.
Non-restricted weight-bearing after modified Lapidus arthrodesis
Authors: Pellegrini Manuel , Carcuro Giovanni , Cuchacovic Natalio , Muñoz Gerardo , Somarriva Marcelo
Published: September 2017

Category:

Bunion, Midfoot/Forefoot

Introduction/Purpose:

Modified lapidus arthrodesis is performed in the treatment of different pathologies, including hallux valgus and osteoarthritis of the first cuneo-metatarsal joint. Complications of this procedure include delayed union and non-union, reported to be between 5 to 20%. To prevent them, prolonged foot unloading and rigid fixation methods have been proposed. We sought to investigate our clinical results and complications in patients operated on with a modified Lapidus arthrodesis and inmediate weight bearing in a rigid post-operative shoe.

Methods:

After IRB approval, we conducted a retrospective patient chart review in a single center. Dedicated foot and ankle orthopaedic surgeons performed all procedures. Patients were included if they were older than 18 years, had a minimum follow up of one year and agreed to participate in the study. Patients with neuropathy, revision arthrodesis or those with concomitant midfoot/hindfoot procedures were excluded. All patients were operated on with an inter-articular lag screw and a locking neutralization plate. Patients were allowed to weight bear without restriction in a rigid post-operative shoe from postoperative day one. An independent musculoskeletal radiologist evaluated bone consolidation of the arthrodesis in x-rays or CT scan, when available.

Results:

Fifteen patients (18 feet) with an average age of 47 years (15-66) met inclusion criteria. All patients were female. Mean follow up was 19 months (12-24). Surgical indications were: hallux valgus in 14 cases and cuneo-metatarsal osteoarthritis in one case. Consolidation rate was 94% (14/15). Average time for radiological consolidation was 11 weeks (7-27). One patient (6%) developed non-union and required a revision arthrodesis with bone grafting. No loss of radiological correction or malalignment of the first ray was observed at last follow-up.

Conclusion:

Our results suggest that modified lapidus arthrodesis with rigid fixation methods and non restricted weight bearing is a safe and effective alternative to manage first ray pathology. This approach may not increase non-union rates or affect the reduction obtained.
Utilization of Retrofusion screw for PIP fusion for treatment of hammertoes
Authors: Ran Henry , Palisch Andrew , Ahuero Jason
Published: September 2017

Category:

Lesser Toes

Introduction/Purpose:

The rigid hammertoe deformity requires realignment of the proximal interphalangeal joint. Traditionally this has been achieved with resection arthroplasty with K-wire fixation of the joint. However, this method is prone to complications such as pin migration, pin tract infection, pin breakage, nonunion, and malunion. Recently, a variety of treatment options have been developed to achieve appropriate PIP joint fusion while minimizing these risks. This study investigates the fusion rate and outcomes of a novel internal fixation screw.

Methods:

A retrospective review was done to determine the short term fusion and satisfaction rate of hammertoe corrections performed by 2 surgeons utilizing a specifically designed longitudinal compression screw. A typical dorsal approach to the PIP joint was performed, followed by a resection arthroplasty, and the screw was inserted in the appropriate described manner. At the last follow up, the radiographs and clinical condition was observed. The fusion and alignment of the joint were then analyzed by an orthopaedic resident (PGY3), an orthopaedic attending, and a musculoskeletal radiologist. Clinical satisfaction and appearance was derived from chart review. A total of 55 screws were placed in 40 patients. Thirty-nine of these toes were second toes, 12 were third toes, and 4 were fourth toes. This implant was not designed for the fifth toe. The median final X-ray follow up was 10 weeks (range 5 to 40 weeks).

Results:

After evaluation of the post-operative X-rays by all 3 evaluators, at least 76% of these toes were definitively fused. About 13% of the joints were difficult to judge for radiological union based on the available X-rays. Approximately 11% of the joints went into nonunion or were not fused by final (typically asymptomatic) follow up. Two toes (3.6%) had persistent pain and swelling at the last visit. Two toes (3.6%) had slight misalignment (more than 5 degrees of varus/valgus), and only one was a cosmetic issue. No toes changed in alignment from the immediate post-operative position. There was no evidence of post- operative infection in the entire series. None of the toes required a return to the operating room for any reason.

Conclusion:

Compression screw fixation for the treatment of hammertoe deformities is a relatively effective method in that it demonstrates reasonable rates of radiographic union with very high rate of symptomatic relief. There were no complications associated with infection or loss of alignment. Furthermore, even in patients without firm evidence of bony union, the presence of an intramedullary implant maintains alignment while relieving symptoms.
Lateral Ankle Instability Surgical Treatment
Authors: Sahranavard Bahman , de Cesar Netto Cesar , Shah Ashish , Hudson Parke , Araoye Ibukunoluwa , Cone Brent , Pinter Zachariah , Lee Sung , Jones Caleb , Bergstresser Shelby , Johnson Michael
Published: September 2017

Category:

Ankle, Sports

Introduction/Purpose:

Lateral ankle instability is a common cause of disability in the active population. Although the majority of patients can be treated conservatively, surgical repair of the ligaments, with or without reinforcement, represents an excellent option for refractory cases. Failed primary surgical repair, recurrence of the ankle instability and need for revision surgery can rarely happen and is probably affected by multiple variables. That includes patient’s characteristics such as BMI and comorbidities and surgical aspects such as the use of suture anchors and soft-tissue reinforcement. The purpose of this study was to compare patient’s characteristics and complication rates of primary repair and revision procedures.

Methods:

We retrospectively reviewed 231 patients (160 Female, 71 Male) who underwent surgical treatment for lateral ankle instability between 2010-2016. Thirty-two were revision cases (14.2%), including 24 females and 8 males, and 199 were primary direct repairs (85.8%). The mean age at the time of the surgery was 39 (19-65)years, and average follow-up was 9 (2-55) months. The procedures were performed by four different surgeons. All cases were reviewed based on age, gender, BMI, procedure type and number of incisions, comorbidities, and complications. Data found was compared between the two groups (primary repair and revision surgery) by T-test. A p-value <0.05 was considered significant.

Results:

The Brostrom-Gould procedure was used in 69.5% of the primary repairs and 63.6% of the revision cases. The use of suture anchors was also similar in both groups (51%). Repair of the calcaneofibular ligament was performed in 68% of primary repairs and 81.8% of the revisions. We didn’t find significant differences regarding comorbidities between two groups: smoking (23.4% x 27.2%, p-value 0.371); diabetes (6.8% x 6%, p-value 0.951) and body mass index above 30 (28.5% x 24.2%, p-value 0.347). We found significant difference in the complication rate of the procedures, with a higher incidence in the revision group (48.4%) when compared to the primary repair group (24%). That included: sural neuritis (15.1% x 3.4%), superficial peroneal neuritis (12.1% x 4.5%), skin problems (9% x 7.4%).

Conclusion:

Our study of 231 patients that underwent surgical treatment for lateral ankle instability found significant higher incidence of complications in patients who had revision procedures when compared to primary repair. No differences regarding smoking status, diabetes and BMI were found.