bluuebunny/crossref_metadata_2025 huggingface dataset:
Mid Term 5-Year Follow Up of a Novel Algorithm for Non-Operative Weber B Ankle Fractures
Authors: Rooney Edward M , Finney Fred T , Talusan Paul , Holmes James R , Walton David
Published: October 2019

Category:

Ankle, Ankle Arthritis, Trauma

Introduction/Purpose:

It is important to understand which isolated fibular fractures require surgical intervention. Several different radiographic guidelines have been used to interpret and predict stability of the injured ankle. Holmes et al previously described a novel algorithm used to assess stability and the ability to treat the stable injuries non-operatively. The one year results demonstrated favorable outcomes of these non-operative patients, however there is a question about the durability of these results and whether these patients developed post-traumatic degenerative changes over mid to long term follow up.

Methods:

An observational study based on a previous cohort of 51 patients studied from 2010 to 2013 with isolated Weber B ankle fractures was performed. These were defined as stable at the time of injury when the medial clear space (MCS) was less than 7 mm on the initial gravity stress radiographs along with a normal mortise relationship on weight bearing radiographs. 27 patients that were treated non-surgically, were brought back for a mid-term follow up with a mean of 6.8 years. American Orthopaedic Foot & Ankle Society (AOFAS) Hindfoot scores, Olerud-Molander Ankle (OMA) Score, and visual analog scale (VAS) pain score were collected in accordance with the prior study. Patient Reported Outcome Measurement Information System (PROMIS) scores were also collected including lower extremity, physical function, depression, and pain interference. Standing bilateral ankle radiographs were obtained, and assessed for MCS widening, and ankle arthritis using the Kellgren-Lawrence grading scale.

Results:

Average functional score results were (in comparison to 1-year outcomes): AOFAS Hindfoot, 95.7 (93.2); OMA Score, 95.2 (91.0); and visual analog scale pain score, 0.24 (0.57). Using a Wilcox Signed Ranks Test, there was a statistically significant increase in 5-year AOFAS Hindfoot scores as compared to 1-year scores in those same patients (p=0.005) There was no evidence of significant post-traumatic osteoarthritis based on the Kellgren-Lawrence grading scale.

Conclusion:

The previously described, novel at the time, algorithm for assessing stability of isolated Weber B ankle fractures and nonsurgical treatment with protected weight bearing has shown to produce excellent results for mid-term follow up with an average of 6.8 years. Additionally, these patients are not at increased risk for rapid progression of post-traumatic osteoarthritis. This further supports initial weight bearing radiographs as a reasonable assessment of ankle stability and validates the aforementioned algorithm as a safe and cost-effective functional treatment regimen.
Short-Term Results of Lisfranc Injuries Treated with the Suture Button Technique
Authors: Saito Guilherme H. , Mendes Alberto A. M. , Nishikawa Danilo R. C. , Devito Beatriz , Netto Cesar de Cesar , Devito Leticia , Prado Marcelo P.
Published: October 2019

Category:

Midfoot/Forefoot, Sports, Trauma

Introduction/Purpose:

Primary fixation with screws or plates or primary arthrodesis are considered the gold-standard surgical treatment options for Lisfranc injuries. However, drawbacks of these procedures include loss of joint motion, need for later hardware removal, injury of the articular surface by screws and nonunion. Interosseous suture buttons can be used as an alternative technique for fixation of Lisfranc lesions. Theoretically, it may overcome the disadvantages of the rigid construct provided by plates and screws and minimize the harm to the joint cartilage. The aim of the present study was to provide the short-term results of Lisfranc injuries treated with the suture button technique.

Methods:

Sixteen consecutive patients with Lisfranc injuries requiring an operation were treated with the use of the Mini Tight Rope (Arthrex, Naples, FL) between April 2014 and November 2017. Medical records and radiographic images were retrospectively analyzed by independent observers with respect to functional outcomes, complications, need for reoperation and radiographic outcomes. The mean follow-up was 32 (range, 6-49) months. Functional outcomes were measured by the AOFAS midfoot score and the Visual Analogue Scale (VAS) at the latest follow-up.

Results:

At a mean follow-up of 32 months, the average AOFAS score was 95.8 (range, 82-100) and the mean VAS was 0.6 (range, 0-2). All patients but one were able to return to their previous activities. Twelve patients were very satisfied with the outcomes and four were satisfied or partially satisfied. A total of 9 complications were observed in 6 patients, with discomfort on the button insertion site being the most common (4 cases). Other complications included evidence of radiographic arthritis (3 cases), loss of reduction (1 case) and extensor hallucis longus tendinopathy (1 case). Only 1 patient required a reoperation for removal of the suture button.

Conclusion:

The use of the suture button for fixation of Lisfranc injuries showed excellent results in the short-term. This technique is potentially less harmful to the articular cartilage and generally does not require hardware removal. However, arthritis and/or loss of reduction were noted in 3 patients during follow-up, which could have been caused by the severity of the primary injury itself or by a lack of stability provided by the construct. Further studies are required to evaluate whether the suture button technique provides enough fixation to maintain reduction and prevent the development of arthritis in the long-term.
Fatigue Strength of Highly Crosslinked Polyethylene in Total Ankle Arthroplasty
Authors: Schipper Oliver N. , Dharia Mehul A. , Hertzler Justin S. , Bischoff Jeffrey E.
Published: October 2019

Category:

Ankle

Introduction/Purpose:

Highly crosslinked polyethylene (HXLPE) was developed for its superior wear properties in comparison to conventional polyethylene (CPE). The higher dose irradiation required for HXLPE may also cause embrittlement, which reduces fatigue resistance and leads to surface cracking or fracture of the polyethylene bearing. Concern over fatigue resistance has prevented widespread adoption of HXLPE for use in in total ankle arthroplasty (TAA). The aim of this study was to determine whether HXLPE has sufficient fatigue strength for total ankle arthroplasty under simulated physiologically relevant motion profiles and loading in the ankle.

Methods:

A bicondylar, semi-constrained HXLPE TAA design was subjected to 10 million cycles (Mc) of fatigue testing under loading conditions representative of a walking gait. Kinetics and kinematics of gait were incorporated into a computational model (Dassault Systemes / SIMULIA, Johnston, RI), for prediction of peak stresses on the HXLPE insert. Based on predicted peak stresses, worst case component size and loading configuration were identified. Ten samples were tested on a closed loop servohydraulic test frame (MTS Systems Corp., Minneapolis, MN) for 10Mc. Testing was conducted to a peak load of 5600 N (1259lbs), representing approximately 5 times body weight for a 240 lb individual. Following testing, all samples were evaluated for evidence of polyethylene fracture or surface cracking.

Results:

Peak stresses in the HXLPE insert occurred during heel off, closely corresponding to both peak axial force and dorsiflexion during gait. The smallest sized component had the highest polyethylene insert stresses, whereas larger sized components had more material to bear the same load, resulting in up to a 30% decrease in stress. All 10 specimens completed 10Mc of testing at 5 times body weight without fracture or surface cracking of the polyethylene insert.

Conclusion:

HXLPE has sufficient fatigue strength to withstand 10Mc of loading at 5 times body weight at the point of peak stresses during gait in total ankle arthroplasty, and therefore, may be mechanically strong enough to withstand the demands of the ankle. Further clinical evidence is necessary to determine if these results translate to adequate fatigue strength with clinical use of HXLPE.
Minimally Invasive Knotless-Bridge Suture Technique for Acute Achilles Tendon Rupture
Authors: Shi Zhongmin , Wang Xiaokang
Published: October 2019

Category:

Hindfoot

Introduction/Purpose:

To investigate the clinical effect of minimally invasive knotless-bridge suture technique combined with PRP augamentation for acute achilles tendon rupture.

Methods:

Totally 23 cases of acute achilles tendon rupture were treated from August 2016 to December 2016 including 21 cases of males and 2 cases of females with an average age of 42.1 years-old (from 29-51 years). Mini-invasive knotless-bridge suture technique was performed in all cases until the soft tissue condition improved. Ankle range of motion, calf circumference difference between two lower extrenities, number of repetions for single heel-rise in one minute, American Orthopaedic Foot & Ankle Society (AOFAS) score, The Achilles Tendon Total Rupture Score(ATRS) and time to return to work were investigated at last follow-up, as well as complications during follow-up.

Results:

23 cases were followed for an average of 28 months . At last follow-up, the average ankle ROM was 60.3±2.2°, calf circumference difference between two lower extrenities was 92.7±1.8%, number of repetions for single heel-rise in one minute was 25±2, AOFAS score was 91.5±2.2, ATRS score was 92.6±2.4, time to return to work ranged from 6 to 9 weeks, averaging 7 weeks.Wound was sutured in one stage and united in one stage.No skin necrosis, superficial infection, sural nerve injury occurred.No achilles tendon re-rupture was seen during follow-up.

Conclusion:

Minimally invasive knotless-bridge suture technique combined with PRP augamentation for acute achilles tendon rupture is operated easily and lesser-trama, enabling patients to return to work earlier and proved to be an effective treatment.
The Relationship of the Lapidus Intramedullary Nail to Neurologic and Tendinous Structures in the Foot: An Anatomic Study
Authors: Shofoluwe Ademola , Krautmann Kurt , Marques Lucas , Stewart Gary
Published: October 2019

Category:

Bunion, Midfoot/Forefoot

Introduction/Purpose:

The lapidus procedure is a longstanding operation performed for the treatment of hallux valgus deformity with a concomitant hypermobile first ray. Orthopaedic surgeons have a myriad of options to choose from in performing the lapidus procedure. The implantation of orthopaedic implants comes with the risk of iatrogenic injury to surrounding anatomy. Several cadaveric studies in the humerus and femur have described potential neurovascular structures at risk during placement of intramedullary nail systems. The purpose of this study was to determine the proximity of nail insertion and interlocking mechanisms in the Lapidus Phantom Intramedullary Nail System (Paragon 28, Inc.) to neurologic and tendinous structures in the foot.

Methods:

A titanium intramedullary nail was inserted from the first metatarsal to the medial cuneiform spanning the first tarsometatarsal joint in 10 fresh-frozen cadaver feet. K-wires were inserted in the proximal lateral, proximal medial, and distal medial-to-lateral interlock screw paths. The tibialis anterior tendon, extensor hallucis longus tendon, and superficial peroneal nerve were carefully dissected and exposed, and the distance from each of these anatomic landmarks were then measured and recorded from four different aspects of the nail: Proximal lateral interlocking screw path, proximal medial interlocking screw path, nail insertion, distal interlocking screw path. Distances were averaged, ranges were determined.

Results:

The tibialis anterior tendon was in closest proximity to the proximal medial interlock K-wire with an average distance of 0.4 mm. The proximal medial interlock bisected the tibialis anterior tendon in three of the specimens. The extensor hallucis longus tendon was in closest proximity to the nail insertion with an average distance of 1.2 mm. A branch of the superficial peroneal nerve was in closest proximity to the distal interlock K-wire with an average distance of 7.5 mm, however, the nerve came in direct contact with the proximal medial interlock K-wire in two of the specimens.

Conclusion:

The Lapidus intramedullary nail’s proximal medial interlock screw poses the greatest threat to the tibialis anterior tendon, with the distance from the tendon to the interlock K-wire being 3 mm or less in all specimens tested. The extensor hallucis longus tendon is at risk of injury with insertion of the nail. Medial to lateral interlocking poses the greatest danger to a branch of the superficial peroneal nerve. Blunt dissection should be performed using this system with a path to bone before instrumentation to reduce the risk of nerve and tendon injury in the foot.
Peritalar Motion after Simulated Ankle Fusion in a Cadaveric Model
Authors: Smith Bryan , Schiff Adam , Havey Robert , Pinzur Michael , Muriuki Muturi
Published: October 2019

Category:

Ankle Arthritis, Basic Sciences/Biologics

Introduction/Purpose:

Adjacent joint disease often occurs after many orthopaedic surgical interventions. Specifically in the foot and ankle, subtalar arthritis has been demonstrated as a long term sequelae after ankle arthrodesis. The purpose of this study was to evaluate real time qualitative and quantitative motion differences in the hindfoot and midfoot during simulated gait, both before and after ankle fusion in a cadaveric model. Data recorded from each cadaveric trial is used in conjunction with a CT scan of each specimen, allowing creation of a three-dimensional, real time, anatomic model of motion of the foot and ankle.

Methods:

Three human cadaveric specimens (lower leg and foot) were obtained and prepared for testing. Taking care to preserve the ligamentous and tendinous attachments, radiopaque fiducial makers were placed in each bone (tibia, fibula, talus, calcaneus, navicular, all cuneiforms, 1st metatarsal). CT scan of each specimen was then performed, and used to develop a three dimensional anatomic model of the specimen. Each specimen was then mounted into a custom built apparatus, and load was applied to the construct using a follower load model. Each specimen was taken through two full cycles of the simulated stance phase. Kinematic data of the individual bones/joints were measured in real time, using optoelectronic targets, and saved for later comparison. Next, tibiotalar fusion was performed on each of the previously tested specimens using an anterior plate and screw construct. The specimens were again cycled in the same fashion and data was recorded in the same manner.

Results:

Tibiotalar fusion successfully eliminated motion between the talus and tibia, directly altering the normal kinematics of the foot ankle complex. Quantitatively, the motion at the subtalar and talonavicular joints increased only slightly with fusion. However, this represents a relative increased motion demand at each joint that exceeds what was observed in the non-fusion condition. Qualitatively, the motion curves for the talocalcaneal and talonavicular joints were altered when compared to the non-fusion state (Figure 1). The qualitative change in motion revealed a relative linkage of motion between the subtalar and talonavicular joints and this was consistently observed across all specimens.

Conclusion:

Simulated ankle fusion via an anterior plate and screw construct directly alters the kinematics of the downstream (talocalcaneal and talonavicular) joints. Real time observation demonstrates a relative linkage of the motion occurring in the subtalar and talonavicular joints. This linkage resulted in alteration from the observed physiologic motion that occurred in these joints during the non-fusion condition. These findings may provide insight into the etiology of adjacent segment disease seen in the subtalar and talonavicular joints after ankle fusion.
Durability of Smoking Cessation for Elective Lower Extremity Orthopaedic Surgery
Authors: Smith Danica H. , McTague Michael F. , Weaver Michael J. , Smith Jeremy T.
Published: October 2019

Category:

General Health

Introduction/Purpose:

Smoking tobacco is a risk factor for impaired wound healing, infection, delayed fracture healing, and prolonged hospital stay. Smoking cessation prior to surgery has shown a 40% relative risk reduction in total perioperative complications. The primary purpose of this study is to evaluate the impact of preoperative smoking cessation on long-term smoking habits in patients undergoing elective lower extremity orthopaedic surgery. The secondary outcome is patient-reported effectiveness of smoking cessation method.

Methods:

A retrospective cohort study was performed by identifying all patients who were smokers that were required to quit and subsequently had a normal nicotine/cotinine serum test prior to lower extremity orthopaedic surgery. Attempts were made to contact all patients and administer a survey inquiring about demographics, medical history, smoking history, smoking cessation process, and current smoking status.

Results:

Of 36 eligible patients, 23 completed the survey. Eleven patients identified as current non-smokers (48%) at the time of survey follow-up (mean follow-up 55 months with a range of 12 to 88 months). Of these 11, 82% said they were very likely to continue to refrain from smoking. Twelve patients identified as current smokers at the time of survey, over half of whom ceased smoking for at least three months perioperatively. The reasons for resuming smoking were “stress” (45%), ”falling back into the habit” (37%), and due to “friends who smoke” (18%). The majority of smoking patients (92%) decreased the number of cigarettes they smoked regularly. The most effective smoking cessation techniques were ”cold turkey”, “non-nicotine medication”, and ”trans-dermal nicotine patches”.

Conclusion:

Elective surgery offers a unique opportunity for smoking cessation. Of 23 patients required to quit smoking prior to surgery, 48% maintained smoking cessation at least one year postoperatively. Of the 12 patients who relapsed, 55% stated that they did not resume smoking until at least three months postoperatively, suggesting that this particular period may be an important time for intensified smoking cessation counseling.
Comparison of Custom 3D Printed Spherical Implants vs Femoral Head Allografts for Tibiotalocalcaneal Arthrodeses
Authors: Steele John R. , Cunningham Daniel J. , Adams Samuel B.
Published: October 2019

Category:

Ankle Arthritis, Hindfoot

Introduction/Purpose:

Tibiotalocalcaneal (TTC) arthrodesis is a common treatment option for hindfoot arthritis, deformity correction and salvage of failed total ankle replacement. However, union can be difficult to achieve in patients with bulk bone defects. Femoral head allograft is commonly used in the setting of TTC fusion with severe bone loss, but recent studies have reported concerns of arthrodesis rates of 50% or worse and graft collapse in these patients. Retrograde intramedullary nail placement through custom 3D spherical implants is a novel option for these patients. The purpose of this study was to compare fusion rates, graft resorption and complication rates between patients undergoing TTC fusion with 3D sphere implants versus femoral head allografts.

Methods:

All patients who underwent TTC arthrodesis with an intramedullary nail along with a 3D spherical implant or femoral head allograft by the senior author at a single institution from 2013 to 2017 and who had at least one year of follow-up were included in this study. There were 7 patients who received a femoral head allograft and 8 patients who received a 3D printed sphere. Baseline patient and operative characteristics were collected and compared between the 3D sphere and femoral head allograft groups. The rate of successful fusion of the tibia, calcaneus and talar neck to the 3D sphere or femoral head allograft, as determined by radiographs and CT scan, as well as graft resorption and complications were compared between the groups.

Results:

The rates of union of the tibia (87.5% vs 71.4%), calcaneus (87.5% vs 71.4%), and talar neck (100% vs 42.9%) were higher in the 3D sphere group than in the femoral head allograft group. The rate of union of the talar neck was significantly higher to the 3D sphere implant than to the femoral head allograft (p=0.016). The number of patients achieving successful fusion of all three articulations was higher in the 3D sphere group (75%) than the femoral head allograft group (42.9%), although not statistically significant (p=0.22). The rate of graft resorption was significantly higher in the femoral head allograft group (57.1%) than the 3D sphere group (0%, p=0.016).There were no differences between the groups in terms of complications.

Conclusion:

These data demonstrate that the use of a custom 3D-printed sphere implant is safe in patients with severe bone loss undergoing TTC arthrodesis with a retrograde intramedullary nail. The rate of successful fusion of all three tibial, calcaneal and talar neck articulations was higher to the 3D sphere than to the femoral head allograft, although not statistically significant. Union of the talar neck was significantly higher to the 3D sphere implants than it was to the femoral head allograft. Subsidence was significantly higher with the femoral head allograft than the 3D sphere.
Defining Responders vs Non-Responders After Total Ankle Arthroplasty
Authors: Steele John R. , Cunningham Daniel J. , DeOrio James K. , Nunley James A. , Easley Mark E. , Adams Samuel B.
Published: October 2019

Category:

Ankle, Ankle Arthritis

Introduction/Purpose:

The literature for total ankle arthroplasty (TAA) demonstrates significant improvements in patient- reported outcomes. While these reports focus on the overall study population, it is clear that some patients do not have a successful outcome. In regards to total hip and knee arthroplasty there is literature helping to define responders, or those who achieve a clinical improvement above the level of a minimally clinically important difference. However, characteristics of responders versus non-responders to TAA have not been defined. The purpose of this study was to determine patient comorbidities and characteristics that help distinguish responders from non-responders after TAA.

Methods:

Patients undergoing TAA between 1/2007 and 12/2016 were enrolled into a prospective study at a single academic center. Patients completed multiple patient reported outcome measures before surgery and in follow-up including the Short Musculoskeletal Function Assessment (SMFA). Patients were characterized as responders if their 2-year follow-up SMFA function score increased by 50% or more compared to preoperatively and were characterized as non-responders if their SMFA score increased by less than 50% at 2-year follow-up, consistent with OMERACT–OARSI responder criteria. Patient and operative factors along with prevalent pre-operative comorbidities were then associated with responder or non-responder status. Comorbidities that met a significance threshold of p<0.05 in adjusted analyses were incorporated into multivariable outcome models.

Results:

A total of 492 patients with complete data and 2-year follow-up were included in this study. Based on the SMFA function score improvement cutoff of at least 50% at 2-year follow-up, 332 patients were defined as responders and 160 were defined as non-responders. There was no significant difference between pre-operative SMFA function scores between the groups. Responders had significantly higher preoperative SF-36 Mental Component Summary (MCS) scores (p<0.001) and significantly lower rates of rheumatoid arthritis (p<0.001), obesity (p=0.05) and depression (p=0.026) as compared to non-responders. In multivariate analysis, preoperative SF-36 MCS score was found to be significantly associated with responder status (p=0.0056).

Conclusion:

Patients defined as responders after TAA based on 50% or greater improvement in SMFA function scores at 2-year follow-up had significantly higher pre-operative SF-36 MCS scores and significantly lower rates of rheumatoid arthritis, obesity and depression compared to non-responders. Pre-operative SF-36 MCS score was found to be significantly associated with responder status in multivariate analysis. This suggests that patients with depressive symptoms, but not necessarily a diagnosis of depression may not achieve as favorable results after TAA and should be counseled appropriately.
Syndesmotic Fixation Utilizing a Novel Metal Screw: A Retrospective Case Series Reporting Early Clinical and Radiographic Outcomes
Authors: Stenquist Derek S. , Velasco Brian , Cronin Patrick K. , Briceno Jorge , Miller Christopher , Kwon John Y.
Published: October 2019

Category:

Ankle

Introduction/Purpose:

Syndesmotic disruption occurs in nearly 1 in 5 ankle fractures and requires anatomic reduction and internal stabilization to maximize functional outcomes. There is growing evidence to support retaining syndesmotic hardware from both a functional and economic standpoint. However, although broken screws are typically of little consequence, the location of screw breakage can be unpredictable and cause painful bony erosion and difficulty with extraction. The purpose of this investigation is to report early clinical and radiographic outcomes of patients who underwent syndesmotic fixation using a novel metal screw with a more predictable break point and design features to allow for easier extraction.

Methods:

We performed a retrospective review of all consecutive patients who underwent syndesmotic fixation utilizing the novel syndesmotic screw over a one year period. Demographic data were obtained such as age, gender, fracture classification and relevant comorbidities. Screw specific data were obtained such as number of screws utilized and length. Screw loosening or breakage was documented. Postoperative radiographs were reviewed and tibiofibular overlap, tibiofibular clear space and medial clear space were measured.

Results:

18 patients met inclusion criteria. Mean length of clinical follow-up was 4.67 months (range 0.5 to 8.5 months). Per the Lauge Hansen classification, 14 injuries were supination external rotation type, two were pronation abduction and two pronation external rotation type. Three screws (12.5%) fractured at the break point with no screws fracturing at a different location. 21 screws did not fracture with 10 (42%) of the screws demonstrated to be loose. There was no evidence of syndesmotic diastasis or mortise malalignment on final follow up of the cohort. No screws required removal during the study period. There were no other complications of any type (Table 1).

Conclusion:

Early reporting of outcomes is essential to maximize both safety and value in healthcare technology innovation. This study provides the first clinical data on a novel alternative to traditional screws and suture button devices for fixation of syndesmotic injuries. At short-term follow up, there were no complications and the novel screw provided adequate fixation to allow healing and prevent diastasis. While initial results are favorable, longer term follow-up is required to determine whether this novel implant can reduce rates of symptomatic hardware requiring removal, which could ultimately make them more cost- effective than suture-button fixation.
A 10-year Retrospective Case-Series of Venous Thrombo-Embolism frequency in Patients Treated with Total Contact Casts
Authors: Tonge Xenia , Widnall James , Jackson Gillian , Platt Simon
Published: October 2019

Category:

Diabetes

Introduction/Purpose:

Venous Thrombo-Embolism (VTE) is a recognized complication of lower limb immobilization. In the neuropathic patient total contact casting (TCC) is used in the management of acute charcot neuroathropathy and/or to off-load neuropathic ulcers. To our knowledge, there is currently no literature stating the prevalence of VTE in patients, despite the possibility of prolonged lower limb immobilization. There are also no recommendations regarding VTE prophylaxis in the setting of TCCs. We report a retrospective case series assessing the frequency of symptomatic VTE in the patients treated with TCCs. Given that diabetic foot disease manifests as one of many co-morbidities in this medically complex group of patients we hypothesize that the rate of occurrence of VTE should be higher than that of the general population.

Methods:

Patients undergoing TCC between 2006 and 2018 were identified using plaster room records. These patients subsequently had electronic clinical letters and radiological reports assessed for details around the TCC episode, past medical history and any VTE events.

Results:

There were 143 TCC episodes in 105 patients. Average age at cast application was 55 years. The mean time in a cast was 45 days (range from 5 days to 8 months). 3 out of 4 patients had neuropathy as a consequence of diabetes. One TCC related VTE (0.7% of casting episodes) was documented. This was a proximal DVT confirmed on USS 9 days following cast removal. Only 3 patients received VTE prophylaxis while in TCC.

Conclusion:

Despite these complex patients having a multitude of co-morbidities the frequency of VTE in the TCC setting remains similar to that of the general population. This may be due to the fact that TCCs permit weight bearing or that Charcot arthropathy leads to a high outflow state, potentially turning Virchow’s triad in the patient’s favour. This case series suggests that, while all patients should be individually VTE risk assessed as for any lower limb immobilization, chemical thromboprophylaxis is not routinely indicated in the context of TCCs.
A Novel and Safe Fibular Osteotomy for Total Ankle Replacement through Lateral Transfibular Approach
Authors: Usuelli Federico G. , Kaplan Jonathan RM , Maccario Camilla , Manzi Luigi , Indino Cristian
Published: October 2019

Category:

Ankle Arthritis

Introduction/Purpose:

The lateral transfibular total ankle arthroplasty (TAA) has been reported on with good short term outcomes. One key downside to the lateral TAA is the rate of symptomatic hardware and wound issues requiring hardware removal seen with the short oblique fibular osteotomy. Therefore, we report on a comparative cohort study of lateral TAA using the traditional short oblique fibular osteotomy to a long oblique fibular osteotomy, termed Foot and Ankle Reconstruction Group Osteotomy (FARG).

Methods:

Retrospective identification of primary lateral transfibular TAA performed by a single surgeon from May 2013 to October 2016 with minimum 2 years follow-up. Clinical assessment included patient demographics, wound complications, need for hardware removal, visual analogue scale, American Orthopaedic Foot & Ankle Society score, Short Form-12 Mental Composite Score, and Short Form-12 Physical Composite Score. Radiographic assessment included weight bearing x-rays to assess tibiotalar alignment, implant alignment, and fibular osteotomy healing.

Results:

A total of 159 primary lateral TAA were identified. The short oblique fibular osteotomy was used in 50 cases and the FARG osteotomy in 109 cases. Implant survival was 100% and there were no fibular osteotomy nonunions in both groups. There was improvement in all clinical parameters in both groups with no significant difference between groups in any of these parameters. The radiographic measures showed excellent alignment at all time points in both groups with no significant difference between groups. There was a significant difference between groups in the rate of wound dehiscence and rate of hardware removal for any reason with the FARG osteotomy having a lower rate of both compared to the short oblique fibular osteotomy.

Conclusion:

Modification of the traditional fibular osteotomy to the long oblique Foot & Ankle Reconstruction Group fibular osteotomy has excellent 2-year survival with good clinical and radiographic outcomes yet provides decreased rates of wound complications and decreased rates of symptomatic fibular hardware compared to the traditional short oblique fibular osteotomy.
Return to Sport Following Turf Toe Injuries: A Systematic Review and Meta-Analysis
Authors: Vopat Matthew L. , Hassan Maaz , Poppe Tanner , Tarakemeh Armin , Zackula Rosey , Mulcahey Mary K. , Mullen Scott , Schroeppel J. Paul , Vopat Bryan G.
Published: October 2019

Category:

Sports

Introduction/Purpose:

The prevalence of turf toe injuries has increased in recent years due to heightened awareness and the large number of athletes participating in sports today. Uncertainty remains, however, as to how to properly treat turf toe and the prognosis for these injured athletes. The purpose of this study was to systematically review the literature to provide recommendations on treatment of turf toe and expectations for outcomes and return to play.

Methods:

Following PRISMA criteria, a systematic review and meta-analysis using the PubMed/Ovid Medline/PMC databases was performed (May 1964 – August 2018). Studies evaluating non-turf toe injuries, biomechanical studies, and those written in non- English language were excluded. Return to sport, treatment, severity of injury, athletic position, and sport were recorded and statistically analyzed.

Results:

12/944 studies met criteria, which included 112 athletes and 120 turf toe injuries. The athletes played a variety of sports: football (111), basketball (2), soccer (1), and track (3). 58 of these injuries were treated non-operatively, while 62 required surgery. There was one grade 1 injury, ten grade 2 injuries, and fifty-four grade 3 injuries. Fifty-five injuries were unclassifiable and excluded. Return to sport for patients treated non-operatively was 5.9 weeks versus 19.2 weeks in patients treated operatively (p=0.007). Patients with a grade 2 injury returned to sport quicker (11.7 weeks) than patients with grade 3 injuries (19.9 weeks) (p=0.016). Return to play was different according to the athlete’s level of play (13.9 weeks high school, 16.8 weeks college, 14.4 weeks professional) (p=0.018).

Conclusion:

Return to sport in patients suffering from a turf toe injury can be affected by either the severity of injury and/or level of competition of the athlete. However, this study also acknowledges the limited number of high level studies evaluating turf toe in the athletic population. Further research is necessary to clearly define appropriate treatment and return to play protocols based on sport, position, and level of play.
With Whom Does the Surgeon Spend More Time? A Study of the Orthopaedic Foot and Ankle Clinic
Authors: Wakefield Connor J. , Wu Kevin , Skipor Joe , Ravanam Angad , Benko Savannah , Bohl Daniel D. , Lee Simon , Hamid Kamran S.
Published: October 2019

Category:

Health Sciences Research

Introduction/Purpose:

In the era of decreasing reimbursement and increasing financial pressure on the orthopaedic foot and ankle surgeon, improving clinic efficiency has value. The purpose of this study was to identify which patients and which types of clinical visits consume the greatest amounts of an attending orthopaedic foot and ankle surgeon’s time.

Methods:

A prospective, observational study was conducted in an outpatient orthopaedic foot and ankle clinic at a tertiary medical center. 210 adult patients were enrolled from the clinics of two fellowship-trained, board certified orthopaedic surgeons. Time spent in the exam room with the attending surgeon was the primary outcome. Independent variables included patient and appointment characteristics (i.e. age, sex, new/follow-up appointment, etc.). Linear regression was used to test for association between the independent variables and the primary outcome.

Results:

Mean time spent by the attending surgeon in the exam room (± standard deviation) was 7.4±4.4 minutes (range, 1-20). Predictors of greater time spent in the exam room included patient age≥50 years (+2.0 minutes, 95% confidence interval [CI]=+0.8 to +3.1, p=0.001), female sex (+1.7 minutes, 95% CI=+0.5 to +2.9, p=0.005), outside medical records reviewed (+2.4 minutes, 95% CI=+0.6 to +4.2, p= 0.010), and new (versus follow-up) patient appointment (+1.7 minutes, 95% CI=+0.5 to +2.9; Table 1). In contrast, time spent in the exam room was not associated with the patient arriving late, completion of patient paperwork before the appointment, whether the patient obtained x-rays at the visit, or the type of provider that saw the patient prior to the attending (resident/physician assistant; p>0.05 for each).

Conclusion:

Patients who are age=≥50, identify as female, bring outside medical records for review, and are presenting to the surgeon for the first time consume the greatest amounts of a surgeon’s time in the examination room. Surgeons can anticipate spending more time in the room with these types of patients and should schedule their clinics accordingly.
Effect of Subchondral Bone Condition on Repaired Tissue after Bone Marrow Stimulation for Osteochondral Talar Lesions
Authors: Yoshimura Ichiro , Hagio Tomonobu , Nagatomo Masaya , Minokawa So , Kanazawa Kazuki , Yamamoto Takuaki
Published: October 2019

Category:

Ankle, Sports

Introduction/Purpose:

The arthroscopic bone marrow stimulation (ABMS) promotes repaired tissue healing of the osteochondral defect. Recently, T2 mapping has been used to evaluate the repair of cartilage tissue; however, the prognostic worth of T2 values after ABMS has not yet been clarified. Several articles have reported that the subchondral condition affects the articular cartilage condition, and subchondral bone edema (SBE) is reportedly associated with inferior outcome after ABMS. Furthermore, subchondral bone sclerosis (SBC) was found to be associated with an inferior outcome after ABMS. The purpose of the present study was to investigate the relationship between SBC/SBE and T2 values of repaired tissue on MRI after ABMS. We hypothesized that the presence of SBC/SBE would affect the characteristics of the repaired tissue after ABMS.

Methods:

We prospectively enrolled 18 patients (18 ankles) scheduled to undergo treatment with ABMS for OLT. The patients were six males and 12 females (age, 29.3 ± 22.1 years; lesion length, 10.8 ± 3.0 mm; lesion area, 59.7 ± 26.0 mm2). Repair tissue was assessed using a 3 T MRI unit, and T2 maps were calculated. Patients were divided into two groups for investigating effect of the SBE: those with SBE and those without SBE based on MRI performed pre-ABMS and 1 year post-ABMS. We investigated the relationship between T2 value and SBE presence. For investigating the relationship between SBC and T2 value, the patients were divided into two groups; with SBC and without SBC on pre-ABMS CT images. Clinical results were assessed using JSSF scale.

Results:

There were no significant differences in mean T2 values and JSSF score before ABMS between those with SBE versus those without SBE (T2 values, P = 0.5; JSSF score, P = 0.9). At 1 year post-ABMS, there was no significant difference between groups in T2 value (P = 0.8), but the JSSF score was significantly lower in the SBE group (P = 0.02). No significant mean differences were found in T2 values or JSSF scores between the with SBC and without SBC groups post-ABMS (T2 values, P=0.7 / JSSF scale score, P=0.25).Lesion length/area were correlated with T2 values of repaired tissue (length: r = 0.50, P = 0.005; area: r = 0.29, P = 0.04).

Conclusion:

The presence of pre- and/or post-ABMS SBE does not affect the T2 values of repaired tissue after ABMS for OLT. The presence of SBC prior to ABMS did not affect the T2 values of repair tissue after ABMS. However, post-ABMS SBE was associated with poorer clinical outcome. Larger lesion size is correlated with poorer condition of repaired tissue.
Surgical Results of Plantar Plating for Fifth Metatarsal Stress Fracture
Authors: Young Ki Won , Kim Jin Su , Lee Hong Sup , Jegal Hyuk , Park Young Uk , Lee Kyung Tai
Published: October 2019

Category:

Midfoot/Forefoot, Sports, Trauma

Introduction/Purpose:

The treatment of 5th metatarsal stress fractures of the can be challenging and at times can result in significant disability. Intramedullary screw fixation has become a popular surgical method for management. However, many recent reports have described failures after screw fixation in athletes. The aim of this study was to determine rates of clinical and radiographic fracture healing, return to sport, and complications of elite athletes with proximal fifth metatarsal fracture treated with plantar plating.

Methods:

Thirty-eight patients with fifth metatarsal stress fractures treated using the plantar plating technique in four hospitals from 2013 to 2018 were evaluated retrospectively. All of the patients were elite athletes. Demographic data, radiographic evaluation, and the time until union and return to unrestricted sporting competition were collected and analyzed.

Results:

A total of 38 patients underwent the plantar plating for 5th metatarsal stress fracture with a mean follow-up of 23 months (range, 12-49 months). The mean time to radiologic union as determined by CT was 9.3 weeks (range, 8-16 weeks). However, during follow-up, there were 4 refractures but no union problems. One patient experienced temporary sensory disturbance that resolved within 3 months. There was one patient with temporary wound complication, two cases with hardware prominence. All but one patients were able to return to their previous levels of sporting activity at 21 ± 4 (range, 18 to 40) weeks.

Conclusion:

With minimum 1-year follow-up, the described plantar plating technique is a good alternative method for the surgical treatment of fifth metatarsal stress fractures with less complications.
Cementless vs Cemented Total Ankle Arthroplasty: A Prospective Comparison of the Laterally Placed Trabecular Metal Ankle
Authors: Younger Alastair S.E. , Usuelli Federico G. , Bohay Donald , Krause Fabian , Giza Eric , Patsalis Theo , Parekh Selene G. , Raikin Steve , Ellington Kent
Published: October 2019

Category:

Ankle, Ankle Arthritis

Introduction/Purpose:

The laterally placed trabecular metal ankle replacement is placed using a jig and a fibular osteotomy. The tibia and talus are reamed to match the curved contour of the replacement. Additional fixation is achieved using two rails on the tibial and talar component. Additional cement fixation can be used by a bead of cement on the rail to assist in early component fixation. Cement fixation did not cover the entire ingrowth surface but was only used on the rails as per the technique manual. The purpose of this study is to compare the early results of 113 total ankle replacements with and without rail cement.

Methods:

121 patients were enrolled in a prospective study. 10 centers were involved. 3 patients underwent revision and 5 withdrew (1 death, 2 lost to follow up and 2 requested discontinuation). Patients were assigned cement or no cement based on the surgeons practice. EQ5D, AOFAS, AOS scores were obtained preoperatively and at 6 weeks, 6 months, and yearly thereafter. Revision of metal components for infection or loosening were secondary end points. Statistical significance was tested by the Wilcoxon Signed Rank Test 26 and set at p= 0.05. 95% confidence intervals are given. 59 ankles had cement, and 53 had press fit. The demographics showed the cement augmentation patients were heavier and older. The cement cases had longer surgical times (169 minutes, CI 159 to 179 vs 154, CI 144 to 163). Of 113 cases, 113 were followed at 1 year, and 100 at 2 years and 67 at 3 years.

Results:

The press fit components without cement showed statistically better outcomes at 6 weeks for the AOFAS score. The EQ5D favored the press fit component at 6 weeks, 6 months and 1 year. For the AOS pain scale the 6 month results favored the press fit component, and for the difficulty scale the results favored the press fit components at 6 weeks and 1 year. Survivorship for all joint replacements (revision of metal components) was 96 percent for the total cohort, with 2 metal components in two ankles being revised, both in the cementless group (chi square not significant).

Conclusion:

As all outcomes to date favor press fit fixation there does not seem to be any need to augment fixation with cement in this total ankle design. There were two metal component revisions in the cementless group and one associated with loosening. There major are demographic differences between the groups and so an RCT would be required to correctly answer the question.
Minimum 2 Year Prospective Follow-Up on a Laterally Placed Trabecular Metal Total Ankle Arthroplasty
Authors: Younger Alastair S.E. , Usuelli Federico G. , Bohay Donald , Krause Fabian , Giza Eric , Patsalis Theo , Parekh Selene G. , Raikin Steve , Ellington Kent , Tiusanen Hannu
Published: October 2019

Category:

Ankle, Ankle Arthritis

Introduction/Purpose:

The laterally placed trabecular metal ankle replacement is placed using a jig and a fibular osteotomy. The tibia and talus are reamed to match the curved contour of the replacement. The lateral approach was advocated to reduce the wound complications of the anterior approach. Additional fixation is achieved using two rails on the tibial and talar component. This study outlines the outcomes of 121 ankles followed prospectively with minimum 2 years follow up.

Methods:

121 total ankles were consented to enrollment in a prospective study on outcomes. 10 centers were involved in the prospective study. Enrollment was from 2014 to 2016. 3 patients underwent revision and 5 withdrew (1 death, 2 lost to follow up and 2 requested discontinuation). Demographics were obtained at baseline. The average age was 59.9 at the time of surgery. 48% were male and BMI averaged 29.2. 12.4% had inflammatory arthropathy. EQ5D, AOFAS, AOS scores were obtained preoperatively and at 6 weeks, 6 months, and yearly there after. Revision of metal components for infection or loosening were secondary end points. Statistical significance was tested by the Wilcoxon Signed Rank Test 26 and set at p= 0.05. 95% confidence intervals are given. Of 113 cases, 113 were followed at 6 weeks, 113 at 1 year, and 100 at 2 years and 67 at 3 years.

Results:

AOS Outcomes improved from 59.7 (SD 20.6) to 22 (SD 18) at 6 months, 18.6 (SD 19.6) at 1 year, 19.8 (SD 21) at 2 years and 21.3 (SD 25) at 3 years. AOFAS scores and EQ5 D scores showed similar improvements at all time points. The improvements were significant compared to baseline at all time points (see figure). Survivorship was .98 at 1 year (CI .92 to .99), and .96 at 2 and 3 years (CI .90 to .99). 3 components were revised, a tibial component (loosening), a talar component (instability), and a polyethylene liner (infection).

Conclusion:

The laterally placed trabecular metal total ankle arthroplasty has demonstrated reliable improvements in outcome and an excellent survivorship at minimum 2 years follow up. Longer term follow up and larger series will be required to clearly outline its outcome. This early outcome demonstrates very promising outcomes at 3 years and low revision rates.