bluuebunny/crossref_metadata_2025 huggingface dataset:
Use of Weight-Bearing Computed Tomography in the Evaluation of Abnormal Hindfoot Morphology in Charcot-Marie-Tooth Patients
Authors: Michalski Max , An Tonya W. , Haupt Edward T. , Yeshoua Brandon , Salo Jari , Pfeffer Glenn B.
Published: January 2022

Category:

Hindfoot; Other

Introduction/Purpose:

The hindfoot deformity seen in Charcot-Marie-Tooth disease (CMT) is poorly understood, and the contribution of abnormal bone morphology has never been conclusively demonstrated. The purpose of this study was to compare the three-dimensional (3D) bone morphology of the talus, calcaneus and navicular in a cohort of CMT patients versus a control population. We used the data obtained from weight-bearing computed tomography (WBCT) to reconstruct the geometric shape of each bone using 3D surface meshing techniques. Surface mesh analysis of this type is commonly used in engineering to evaluate and optimize 3D geometries and structures.

Methods:

A total of 17 WBCTs from 15 patients (average age 24) with CMT who underwent WBCT without previous surgeries, degenerative changes or open physes were included. These were compared to 20 healthy control WBCTs. Calcaneal measurements included the radius of curvature and the angle between the posterior tuberosity and posterior facet in the sagittal plane. Talar measurements include axial and sagittal declination between the body and neck as well as coronal rotation of the talar head relative to the body. Surface-mesh model analysis was performed comparing the average of the CMT cohort to the controls using CT analysis software (Disior Bonelogic). Means were compared with a t test (p<0.05).

Results:

CMT patients had significantly less sagittal declination (plantarflexion) versus controls (14.9 versus 25.1 degrees respectively) (p<0.01). Similarly, CMT patients had less talar head coronal rotation versus controls (30.2 versus 42.5 degrees respectively) (p<0.001). There was no difference in axial rotation of the talar neck versus body between the groups (p=0.88). The calcaneal radius of curvature in CMT patients was significantly smaller than the control population (716.6 versus 2143.5 mm respectively) (p<0.05). Angular differences were also significant between the posterior tuberosity and posterior facet of the subtalar joint in the sagittal plane (CMT 57.7 degrees, control 67.9 degrees) (p<0.001). Additionally, surface-mesh model analysis demonstrated the largest differences in morphology at the navicular tuberosity, medial talar head, sustentaculum tali and anterior process of the calcaneus (Figure 1).

Conclusion:

This is the first study to quantify the morphologic differences in osteology seen in CMT patients. The decreased sagittal declination of the talar neck is seen with a reciprocal decreased slope of the posterior facet of the calcaneus. The coronal rotation of the talar head and abnormal navicular tuberosity morphology shows changes seen in patients with CMT and may be attributed to unbalanced pull of the posterior tibial tendon during development. These findings will help refine, and potentially revolutionize the surgical reconstruction of cavovarus deformity in CMT patients.
Declining Trends in Medicare Reimbursement in Orthopaedic Foot and Ankle Surgery
Authors: Miskiel Sandra , Bye Matthew , Freeland Erik C. , Pagliaro Andre J.
Published: January 2022

Category:

Ankle; Ankle Arthritis; Arthroscopy; Bunion; Hindfoot; Lesser Toes; Midfoot/Forefoot; Sports; Trauma; Other

Introduction/Purpose:

With the increasing complexity of physician reimbursement models, understanding reimbursement trends is crucial to the financial sustainability of orthopaedic practices nationwide. Inflation-adjusted Medicare physician reimbursement for total joint arthroplasty has decreased by approximately 33% from 2000 to 2019. Recent trends in orthopaedic foot and ankle reimbursement are unknown. Thus, our study sought to analyze trends in Medicare reimbursement rates from 2000 to 2020 for common orthopaedic foot and ankle surgical procedures.

Methods:

The financial database of a single academic tertiary care center was queried to identify the CPT codes most frequently utilized in orthopaedic foot and ankle care. Next, the Physician Fee Schedule Look-Up Tool from the Centers for Medicare & Medicaid Services was queried for the top 30 CPT codes utilized, and physician reimbursement data extracted. Monetary data was subsequently adjusted for inflation utilizing the consumer price index and reported in 2020 US dollars (USD). Average annual and the total percent change in reimbursement were calculated for included procedures.

Results:

After adjusting for inflation, the average physician reimbursement decreased by 31.6% for all included foot and ankle procedures from 2000 to 2020, with 23/30 codes decreasing by more than 30%. The greatest decrease in reimbursement observed from 2000 to 2020 was for open treatment of calcaneal fracture at 48.3% ($2,254.17 to $1,164.97), followed by flexor tendon repair at 48.2% ($741.02 to $357.39), and open treatment of pilon fracture at 43.9% ($2,451.37 to $1,076.36).

Conclusion:

Over the past two decades, physician reimbursement for foot and ankle procedures has dramatically decreased by up to 48.3%. Continued downward trends in orthopaedic foot and ankle physician reimbursement may lead to decreased access to quality foot and ankle care.
The Intercalary Fragment in Posterior Malleolus Fractures: Characterization and Significance
Authors: Umbel Benjamin D. , Myers Devon , Taylor Benjamin C. , Buchan John A. , Melaragno Anthony J.
Published: January 2022

Category:

Trauma

Introduction/Purpose:

Methods of fixation in ankle fractures involving the posterior malleolus have become increasingly scrutinized. With the increase in computed tomography (CT), an intercalary fracture fragment (ICF) adjacent to the posterior malleolus has often been described. Treatment of this intercalary comminution remains controversial. The primary goal of this study was to compare clinical and radiographic outcomes in patients who had direct reduction and fixation of this fragment compared to those where the ICF was removed or not reduced prior to posterior malleolus fixation.

Methods:

This retrospective study included 249 trimalleolar and posterior pilon ankle fractures grouped into those who had the ICF reduced and fixed (n=74) and those where the ICF was not directly addressed or excised (n=175). CT scans were evaluated for size and location of the ICF. Demographic, radiographic and intraoperative variables were collected and analyzed. The Kellgren and Lawrence classification system was utilized to grade severity of post-traumatic arthritis during the follow up period. Chart review was performed assessing time to weightbearing, repeat surgeries and post-operative complications.

Results:

For the group which had the ICF reduced and fixed, follow up radiographs demonstrated significantly worse Kellgren- Lawrence scores compared to the group that did not specifically reduce the ICF (p< 0.05). There was also a higher rate of repeat surgery in the group which had the ICF fixed, although not meeting statistical significance. There were no differences in size or location of the ICF fragment between groups. The average overall time to weightbearing amongst all patients was 9.7 +- 3.8 weeks. There was no significant difference between time to weightbearing between groups (p = 0.6). There was no significant difference in need for secondary surgeries or post-operative deep and superfical infections.

Conclusion:

With the widespread utilization of CT-scans for preoperative planning of ankle fractures involving the posterior malleolus, there has been greater discussion surrounding the optimal management of the ICF when present. In our study, the primary aim was to explore radiographic changes in patients after direct reduction and fixation of this ICF compared to those without ICF fixation. We demonstrated significantly worse radiographic outcomes following attempted direct reduction and fixation of the ICF. Our results suggest that while concentric joint reduction and syndesmosis stabilization are of utmost importance, attempting to reduce and fix the ICF may lead to worse radiographic outcomes.
Suture Tape Reinforcement Device as an Independent Fixation Solution for Partial Syndesmosis Injuries
Authors: Waryasz Gregory R. , Ogawa Takahisa , Lubberts Bart , DiGiovanni Christopher W. , Guss Daniel
Published: January 2022

Category:

Ankle; Arthroscopy; Basic Sciences/Biologics; Sports

Introduction/Purpose:

A suture tape reinforcement device is designed for repair of syndesmotic injury. Its insertion in the fibular and tibial footprints of the anterior inferior tibiofibular ligament (AITFL) promises a dynamic constraint to external rotation, antero-posterior translation of fibula and diastasis of the syndesmosis in the coronal plane.We hypothesized that following fixation of transected syndesmosis with suture tape reinforcement, syndesmotic stability becomes similar to that of an intact syndesmosis.

Methods:

Fifteen non-paired fresh frozen cadaveric specimens amputated above the knee were included in this study. Assessment of the ankle syndesmosis was performed in six stages; 1) with all syndesmosis ligaments intact; 2) after transection of the AITFL, 3) the interosseous ligament, 4) subsequent fixation with suture tape reinforcement device, 5) transection of the posterior inferior syndesmotic ligament, and 6) after removal of the suture tape reinforcement device (complete ligament transection stage). Instability measurements included anterior and posterior tibiofibular spaces measured arthroscopically under 100N lateral stress using a bone hook, tibiofibular anteroposterior and posteroanterior translation in sagittal plane measured arthroscopically under sagittal stress of 100N, and anterior tibiofibular space measured directly with a caliper under external rotation torque of 7.5 Nm. Instability measurements taken after each fixation method were compared with the intact stage and to the complete ligament transection stage using the Wilcoxon signed-rank test.

Results:

The suture tape reinforcement device was able to stabilize an AITFL- and the interosseous ligament-transected stage, similar to the intact stage, with respect to all measures of instability. As for the complete ligament transection stage, after suture tape reinforcement it remained unstable in the coronal plane, compared to the intact stage: there was an increase in anterior tibiofibular space without stress (1.7 mm vs 1.1 mm, p=0.005) and with stress (1.8 mm vs 1.1 mm, p=0.007), as well as in posterior tibiofibular space with stress (2.8 mm vs 1.6 mm, p=0.002).

Conclusion:

Our findings suggest that suture tape reinforcement device might be effective for fixation of partial syndesmotic injury, but not for complete syndesmotic injury. Future clinical research is needed to confirm this.
Adolescents with Lisfranc Injury Frequently Have Different Pathology with Higher Incidence of Proximal Extension of the Ligamentous Disruption
Authors: Abdelgawad Amr , Thabet Ahmed
Published: January 2022

Category:

Midfoot/Forefoot; Trauma

Introduction/Purpose:

Lisfranc injuries are rare injuries in the adolescent age group and can be easily missed. Ligamentous Lisfranc injuries have been classically descried as disruption of the Lisfranc ligament (between medial cuneiform and second metatarsus) and ligamentous disruption of the first metatarso-phalangeal joint. The study aimed to report pathological pattern of Lisfranc injury in adolescent patient and if it was different from the common adult forms.

Methods:

This is a retrospective study of patients with Lisfranc injury treated at a Level 1 trauma center between 2012 and 2019. This study has been IRB approved. The inclusion criteria were of adolescents with isolated Lisfranc injuries and treated via surgical intervention. The surgical intervention helped to identify the exact pathology. The study excluded patients over the age of 18, patient with high energy injuries and patients treated non-operatively. Patients' demographics including age and gender, were recorded. Other variables included the mechanism of injury, side of injury, fracture type, the intraoperative findings of the ligamentous injury and follow-up data. Follow up radiographs were reviewed for time to bony union and any post-traumatic complications. Outcomes include wound healing status, the union status of the fracture, and complications that may arise along with treatment and follow-up.

Results:

A total of 9 patients met the study inclusion criteria. Mean age was 15.4 years old, male to female ratio of 5:4, mean follow-up time was 9.5 months. All patients achieved full union at the final follow-up. The postoperative course went without complications except one for patient. The patient had prominent screw under the skin. The screw removed in the office under local anesthesia. Intraoperative findings in 6/9 (66.6 %) cases demonstrated a Lisfranc injury pattern with proximal extension through the inter-cuneiform ligament. Operative treatment in cases of proximal extension included added fixation between the middle cuneiform and middle cuneiform (screws or plates). Also noted in 2 cases, that the 1st tarso-metatrsal joint was not affected (in contrast to classic Lisfranc injury in adults). In these cases, no fixation was need for the 1st TMT joint.

Conclusion:

Lisfranc injury in adolescent has frequently different pathology compared to adults' counterparts. It commonly involves proximal extension with the ligament disruption. It also sometimes spares the ligaments of the 1st TMT joint. Orthopedic surgeons should be aware of these changes as it implies changes in the treatment strategy and fixation construct.
Performance Outcomes after Surgical Repair of Achilles Tendon Rupture in the Women’s National Basketball Association
Authors: Aiyer Amiethab A. , Hodgens Blake H. , Geller Joseph S. , Rizzo Michael G. , Munoz Julianne , Kaplan Jonathan R.
Published: January 2022

Category:

Sports; Ankle

Introduction/Purpose:

Achilles tendon ruptures are devastating injuries in elite athletes. Current literature shows poor prognosis following Achilles tendon rupture in professional male basketball players, however there are currently no studies examining the effects of Achilles tendon rupture on performance outcomes in the Women's National Basketball Association (WNBA). Understanding the impact Achilles tendon rupture has on return to play and performance metrics in the WNBA will provide valuable information to players, team personnel, and medical professionals on post-injury expectations.

Methods:

17 WNBA players who sustained an Achilles tendon rupture from 2000-2019 were identified from publicly available injury reports and player profiles. Demographic information collected included age, body mass index (BMI), position, and service in the WNBA when the tear occurred. Statistics were collected for the season before the injury, and two seasons after the injury, and the Player Efficiency Rating (PER) was calculated. PER is defined as ([points + rebounds + assists + steals + blocks] - [(field goals attempted - field goals made) + (free throws attempted - free throws made) + turnovers]) / games. Controls were matched by service in the WNBA, position, and PER.

Results:

Following Achilles tendon rupture, four players never returned to play in the WNBA, while seven players failed to play >1 season. Players who returned saw a significant decrease in the number of minutes played per game in both their first and second seasons post-injury (mean differences -6.11 and -6.54, respectively, p<0.01). Players also suffered a significant decrease in PER during their second season after injury compared with their pre-injury PER (mean difference -2.53, p=0.024). Compared to healthy controls, players who returned to play were significantly more likely to experience a decrease in minutes played per game at both one and two seasons postoperatively (-6.11 mpg vs +1.05 mpg, p<0.01 and -6.54 mpg vs +0.53 mpg, p= 0.018, respectively), while also experiencing significant per-game decreases in field goals (-0.85 vs + 0.20, p=0.47), free throws (-1.04 vs +0.12, p<0.01), steals (-0.48 vs +0.24, p=0.018), and points scored (-2.89 vs +0.58, p=0.014).

Conclusion:

Achilles tendon rupture and subsequent surgical repair in the Women's National Basketball Association (WNBA) accounted for significantly decreased minutes played and performance outcomes in athletes at one and two years post-operatively compared to both their pre-injury year and healthy matched controls. 23.5% of players failed to return to the WNBA, while 41.2% failed to play >1 season after returning from injury.
Clinical and Radiological Results after Use of A Human Bone Graft (Shark Screw®) in TMT II/+II Arthrodesis
Authors: Amann Pascal , Bock Peter
Published: January 2022

Category:

Basic Sciences/Biologics; Midfoot/Forefoot; Trauma

Introduction/Purpose:

The tarsometatarsal joints, also called Lisfranc-joints, are the joints between the midfoot bones and the tarsal bones. The continuous arthrotic destruction of the tarsometatarsal joints leads to pain and foot deformities. The therapy of choice after failure of conservative therapy is arthrodesis. For this operation there is the possibility of using a transplant screw made of allogenic human bone material (Shark Screw), instead of conventional metal implants. This study investigates the clinical significance and radiological integration of the allogenic bone screw for arthrodesis of the tarsometatarsal joints II/+III.

Methods:

This is a retrospective study involving 20 feet of 17 patients who received TMT II/+III arthrodesis with an allogenic bone screw (Shark Screw) at Speising Orthopedic Hospital in Vienna, Austria. VAS, FFI, FAOS, and AOFAS were used as measures to compare preoperative and postoperative results. Radiologic integration in the recipient bone was also evaluated.

Results:

Comparing preoperative with the postoperative score of 20 feet from 17 patients, a significant reduction of the VAS (pain) from 7,6 points to 1,4 points (p=<0,001)), as well as a decrease of the VAS (function) from 7,25 points to 1,8 points has been observed. Further, a significant reduction of the FFI from 62,3% to 16,7% (p=<0,001), and a significant increase from 29,7 points to 79,9 points of the AOFAS (p=<0,001) was detected. Analyzing the FAOS score, there was a significant (p=<0,001) increase of all subscales (Symptoms, Pain, Function and Quality of life). Moreover, in all cases a good radiological integration into the recieverbone was noticed. As a result the screw was, after a follow-up time from 12 months, no longer distinguishable from the original bone.

Conclusion:

These results demonstrated that the human bone screw used for TMT II/+III arthrodesis has a good outcome and reliable clinical significance. This study may be used for further investigations that should be performed to ensure this result.
The Incidence of Surgical Cancellations: Lessons Learned from the Resumption of Elective Orthopaedic Operating after the First Wave of COVID-19
Authors: Amutharasan Emlyn , Malhotra Karan , Zaveri Amit , Welck Matthew J.
Published: January 2022

Category:

Ankle; Other

Introduction/Purpose:

In the aftermath of the first wave of COVID-19, there was a significant backlog of elective orthopaedic cases. To address this problem, efficient running of theatres with optimal theatre utilisation was paramount. However, as new processes were introduced to reduce transmission risk, 'last-minute' cancellations of patients were inevitable. We report our experience of resuming elective work, with particular focus on surgical cancellations, and lessons learned.

Methods:

This was a retrospective, single centre audit at a specialist elective orthopaedic hospital. We identified and examined all cancellations in foot and ankle cases between June and October 2020. Data was analysed and cancellations were categorised into groups by reason of cancellation.

Results:

There were 36 cancellations out of 193 patients listed (19%). Twenty-one cancellations (57%) were directly related to COVID-19 and its processes. These comprised six patients (17%) with COVID-19 swab related issues including: booking errors, transport problems, non-attendance, and invalid swabs. Three patients (8%) contracted COVID-19 preoperatively. Nine patients (25%) cancelled their procedure at short notice amidst fears of contracting COVID-19 perioperatively. Three (8%) cancellations were due to the patient being unfit on the day of surgery - these issues were not routinely identified at pre-assessment appointments as face-to-face pre-assessment clinics had been suspended. A further 15 cancellations (42%) were due to non- COVID-19 reasons including lack of beds, unwell patients, and patients cancelling for other personal reasons.

Conclusion:

Mitigation of cancellations is a key factor in maintaining theatre utilisation. Based on our experience we recommend thorough counselling of patients regarding the importance of self-isolation prior to surgery and of the pre-operative swab. Having a designated team to manage COVID-19 swabs is also critical. Reinstatement of face-to-face pre-operative assessments may help identify evolving issues and prevent last-minute cancellations. These lessons are pertinent to trusts, particularly as we emerge from subsequent waves of COVID-19.
Cylindrical Osteochondral Allograft for Osteochondral Lesions of the Talus: A Systematic Review
Authors: Azam Mohammad , Davey Martin S. , Colasanti Christopher , Mercer Nathaniel P. , Hurley Eoghan T. , Shimozono Yoshiharu , Kennedy John G.
Published: January 2022

Category:

Ankle

Introduction/Purpose:

Ankle injuries commonly result in damage to the articular cartilage of the talus. The use of cylindrical osteochondral allografts (OCA) for osteochondral lesions of the talus (OLT) smaller than 1.5cm is increasingly common, particularly in cases whereby autologous osteochondral transplantation (AOT) is contraindicated. The primary aim of this study is to systematically review the outcomes of cylindrical OCA for OLT. The secondary aim of this study is to compare the outcomes of cylindrical OCA and AOT in the management of similar cases of OLT.

Methods:

Two independent reviewers searched the literature based on PRISMA guidelines, utilizing the EMBASE, MEDLINE, and The Cochrane Library Databases. Only studies that reported outcomes of cylindrical OCA in the management of OLT were included.

Results:

Overall, 4 studies with 100 patients including 101 ankles were included in this review. Pre-operative OLT characteristics showed 69.3% of OLT lesions were located medially, with a mean lesion size of 1.47cm2 (0.46 - 4.2 cm2). Overall, 16.8% of ankles required surgical revision following cylindrical OCA; 1.0% (1/101) underwent subsequent arthrodesis, 6.9% (7/101) underwent revision osteochondral grafting and 7.9% (8/101) underwent subsequent arthroscopic debridement. Radiological outcomes between the graft failure were reported as 10.0% (3/30), joint space narrowing as 30.4% (14/46), and cysts as 42.9% (27/63). Significantly higher revision rates were reported following cylindrical OCA when compared to AOT at over two years follow up (28.1% versus 6.7%, p = 0.02).

Conclusion:

Our systematic review established that although there are high rates of patient satisfaction following cylindrical OCA for OLT, these are less than those reported with AOT for the same condition. Concerns regarding the rates of radiological deterioration as well as the need for surgical revision may represent harbingers for poorer long-term outcomes.
Use of Extracellular Matrix Cartilage Allograft May Improve Infill of the Defects in Bone Marrow Stimulation for Osteochondral Lesions of the Talus
Authors: Azam Mohammad , Shimozono Yoshiharu , Williamson Emilie , Mercer Nathaniel P. , Hurley Eoghan T. , Huang Hao , Deyer Timothy , Kennedy John G.
Published: January 2022

Category:

Ankle

Introduction/Purpose:

The purpose of this study is to evaluate the effectiveness of Extracellular Matrix Cartilage Allograft (EMCA) as an adjuvant to bone marrow stimulation (BMS) compared to BMS alone in the treatment of osteochondral lesions of the talus (OLT).

Methods:

A retrospective cohort study comparing patients treated with BMS with EMCA (BMS-EMCA group) and BMS alone (BMS group) between 2013 and 2019 was undertaken. Clinical outcome was evaluated with the Foot and Ankle Outcome Score (FAOS) pre-and postoperatively. Postoperative MRIs were evaluated using a modified Magnetic Resonance Observation of Cartilage Tissue (MOCART) score. Comparisons between groups were made with the Man-Whitney U test for continuous variables and the χ2 or Fisher exact test for categorical variables.

Results:

Twenty-four patients underwent BMS with EMCA (BMS-EMCA group) and 24 patients underwent BMS alone (BMS group). The mean age was 40.8 years (range, 19 to 60 years) in BMS-EMCA group and 47.8 years (range, 24 to 60 years) in BMS group (p=0.060). The mean follow-up time was 20.0 months (range, 12-36 months) in BMS-EMCA group and 26.9 months (range, 12 to 55 months) in BMS group (p=0.031). Both groups showed significant improvements in all FAOS subscales. No significant differences between groups were found in all postoperative FAOS. The mean MOCART score in BMS-EMCA group was higher (76.3 vs 66.3), but not statistically significant (p=0.176). The MRI analysis showed that 87.5% of BMS-EMCA group had complete infill of the defect with repair tissue, however less than half (46.5%) of BMS group had complete infill (p=0.015).

Conclusion:

BMS with EMCA is an effective treatment strategy for the treatment of OLT and provides better cartilage infill in the defect on MRI. However, this did not translate to improved functional outcomes compared with BMS alone in the short-term.
Bosch Osteotomy for Hallux Valgus Correction: Results at a Mean 10-Year Follow-Up
Authors: Bernasconi Alessio , Rizzo Maria , Russo Anna Paola , Vallefuoco Salvatore , Guarino Amedeo , Mariconda Massimo
Published: January 2022

Category:

Bunion; Midfoot/Forefoot

Introduction/Purpose:

Boesh osteotomy (BO) is a surgical option for the correction of hallux valgus (HV). The aim of this study was to assess the long-term clinical and radiographic results in a cohort of patients treated at our institution.

Methods:

In this retrospective cohort study, we included 58 HVs (28 right, 30 left) in 46 patients (42 females, 4 males; mean age and BMI at surgery 44 +- 15 (range, 15-64) years and 26 +- 4 (range, 22-38) points, respectively) who underwent HV correction by BO and were followed at a minimum of 7 years. The range of motion (ROM), the American Orthopaedic Foot & Ankle Society's Forefoot scale (AOFAS-FS) and the Visual Analogic Scale (VAS) for pain were recorded. On weightbearing radiographs, the Hallux Valgus Angle (HVA), Intermetatarsal Angle (IMA), the Distal Metatarsal Articular Angle (DMAA) and the Sesamoid position were measured and compared with pre-operative values. The complication rate and first metatarsophalangeal joint stiffness were also assessed.

Results:

At a mean follow-up of 10+-2 (range, 7-17) years, mean+-standard deviation AOFAS-FS and VAS were 89+-11 (range, 67-93) and 2.1+-2.8 (range, 0-7) points, respectively. In 62% of patients there was no pain while in 38% an occasional pain was referred. In 42 (72%) cases there was no limitation in the choice of footwears. Radiographically, we found a significant improvement in the HVA (from 33.9°+-6.7 to 18.8°+-5.6, p<0.001), in the IMA (14.2°+-3.1 to 9.4°+-2.7, p<0.001), in the DMAA (from 30.3°+-6.8 to 11.5°+-5.1, p<0.001) and in the sesamoid position (median value from 3 to 1, p<0.001). In 36 (62%) cases the ROM was greater than 75° while in 22 (38%) it ranged between 30° and 75°. Complications occurred in 6 (10%) cases (3 superficial infections, 1 accidental removal of the K-wire, 1 metatarsal head necrosis and 1 development of osteoarthritis), which did not require any surgery at the longest follow-up.

Conclusion:

Boesh technique provided satisfactory clinical and radiographic outcomes in the correction of Hallux Valgus which persisted at a mean 10-year follow-up. The complication rate was not different from more recent techniques described in literature.
Weightbearing CT Assessment of Foot and Ankle Joints in Pes Planovalgus Using Distance Mapping
Authors: Bernasconi Alessio , Netto Cesar de Cesar , Siegler Sorin , Jepsen Maui , Lintz Francois
Published: January 2022

Category:

Hindfoot; Ankle; Other

Introduction/Purpose:

The goal of this study was to describe the abnormal joint surface interaction at the ankle, hindfoot and midfoot joints in patients presenting with Pes Planovalgus (PP) using three-dimensional (3D) distance mapping on weightbearing computed tomography (WBCT) images by comparing a series of PPs to a series of normally-aligned feet. We hypothesized that in PPs joint interactions would reveal significantly increased spaces in the medial side of the ankle, hindfoot and midfoot joints.

Methods:

In this case-control study, ten feet (10 patients) with asymptomatic PP (cases; N=10) were compared to 10 matched- paired (by age, gender and body mass index) normally-aligned feet (10 patients) (controls; N=10). Three-dimensional models were produced from the images and distance maps representing joint surface configuration were generated for the ankle, hindfoot and midfoot joints. The distance maps for each joint were then compared between the two groups and between regions in the same group.

Results:

In PP patients there was a significantly increased surface-to-surface distance anteromedially at the ankle joint (+46.3%, p<0.001) along with an increased distance on the anterior halves of both the medial (+21.3%, p=0.098) and lateral malleoli (+22.7%, p=0.038). At the posterolateral corner of the posterior facet of the subtalar joint we found an increased surface-to- surface distance (by 57.1%, p< 0.001), while at the talonavicular joint there was a reduction of the distance at the superomedial corner (-20%, p=0.097) along with a significant increase in the upper central (+20%, p=0.039) and lateral (+30.7%, p=0.015) zones. A reduction of the surface-to-surface distance was also observed in three of the four zones of the calcaneocuboid joint. Finally, a statistically significant increase in the mean distance was observed at the naviculocuneiform and tarsometatarsal joints in a range between 38% and 93.4% (p<0.001 in all cases).

Conclusion:

We found significant differences in surface-to-surface interaction at the foot and ankle joints between Pes Planovalgus and normally-aligned controls. Distance mapping on WBCT images could be used in clinical practice as a diagnostic support to gauge the morphological changes of articular spaces occurring in Pes Planovalgus.
Cost-Effectiveness of Weight-Bearing Computed Tomography in Diagnosing Syndesmotic Instability
Authors: Bhimani Rohan , Searle Owen F. , Ashkani-Esfahani Soheil , Waryasz Gregory R. , Kerkhoffs Gino , DiGiovanni Christopher W. , Guss Daniel , Lubberts Bart
Published: January 2022

Category:

Ankle; Sports; Other

Introduction/Purpose:

To optimize clinical outcomes, accurate diagnosis and treatment of syndesmotic instability is critical, but subtle instability can be challenging to identify. Weightbearing computed tomography (WBCT) has proved to be a reliable tool for diagnosing syndesmotic instability under physiologic load. We aimed to examine the cost-effectiveness of WBCT with radiographs and/or conventional CT for the diagnosis of syndesmotic instability from a patient perspective.

Methods:

A decision tree model was constructed to examine the cost-effectiveness of WBCT versus conventional CT (NWB CT) versus weightbearing (WB) radiographs versus non-weightbearing (NWB) radiographs (base case) as initial imaging with additional possible imaging for1268 patients with suspected syndesmotic instability. Patient's clinical and radiological notes were evaluated until the diagnosis of syndesmotic instability was established. The decision tree's probabilities, durations, and image counts were based on patient data. The main outcomes were 1) total imaging costs needed before syndesmotic instability was diagnosed, 2) quality-adjusted life-years (QALYs), 3) incremental cost-effectiveness ratios (ICERs), and 4) overall radiation dose prior to diagnosis. Imaging costs and radiation dose were derived from National Medicare reimbursement rates and the American College of Radiology, respectively. An incremental cost-effectiveness ratio threshold of $50,000 per quality-adjusted life years was used to evaluate cost-effectiveness. In addition, one-way and two-way sensitivity analyses were performed to determine the robustness of our findings.

Results:

WBCT resulted in 0.057 additional QALY gained per week compared with NWB radiographs, indicating WBCT to be more effective than NWB radiographs. Costs for WBCT imaging were $38.71 higher than NWB radiographs for an ICER of $38,563.96/QALY. Applying a commonly used threshold of $50,000 per QALY, the patient's willingness-to-pay for the amount of quality-adjusted life-year gained from using WBCT as an initial imaging modality was $54.41, suggesting WBCT first imaging strategy was a cost-effective intervention. In our study, the cost of WBCT imaging was $157.35. Sensitivity analyses demonstrated that WBCT was more cost effective than NWB radiographs up to a cost of $173.05. Additionally, initial WBCT resulted in lower overall radiation dosage (6.4 uSv) compared to the use of the other three imaging modalities as initial imaging strategy (initial NWB radiographs - 12.41 uSv; initial WB radiographs - 8.30 uSv, NWB CT first - 25 uSv).

Conclusion:

WBCT leads to higher QALYs compared to other diagnostic imaging modalities, resulting in improved outcomes for patients by eliminating redundant imaging.
Anatomy of the Naviculocuneiform Joint
Authors: Borrelli George J. , Qatu Mossub , Traynor Christopher J. , Weistroffer Joseph , Jastifer James R.
Published: January 2022

Category:

Midfoot/Forefoot; Basic Sciences/Biologics

Introduction/Purpose:

The naviculocuneiform (NC) joint has a role in numerous pathologies of the foot and ankle. There is little in the published literature quantifying the cartilage of the articulating surface and its unique anatomical features. The purpose of this study was to quantify and describe the articular surface of the NC joint. Our hypothesis was that the cartilage surface would have anatomic features that would guide surgeons when performing procedures such as joint preparation and screw placement.

Methods:

Twenty cadaver NC joints were dissected, and the articular cartilage quantified by calibrated digital imaging software.

Results:

The mean dorsal to plantar height of the navicular facets was 18mm, with a maximum height not exceeding 21mm. The mean height of the medial, middle, and lateral cuneiform facets was 15mm, 17mm, and 15mm, respectively. The mean length from the medial to middle navicular facet was 14mm, approximately 41.3% the mean length across all three navicular facets (34mm). For the distal navicular articulation, 75.4% of the mean surface area was articular cartilage. For the proximal medial, middle, and lateral cuneiform articulations, 69.6%, 75.7%, and 75.8% of the mean surface areas were articular cartilage, respectively.

Conclusion:

This study provides an anatomic description of the NC joint to guide surgeons when operating on the NC joint. Two clinical observations can be made from this data. First, when preparing the NC joint for arthrodesis from a dorsal approach, the surgeon should be aware that the cartilage of the NC joint can extend up to 21mm from dorsal to plantar. This is also a useful estimate of screw length in the subchondral bone. Second, the central third of the navicular, where the majority of navicular stress fractures occur, lies in the inter-facet ridge between the medial and middle facets.
Medium to Long-Term Results of Combined Deltoid and Foot Reconstruction for PCFD (Stage IV) Valgus Ankle
Authors: Caolo Kristin C. , Netto Cesar de Cesar , Garfinkel Jonathan , Roney Andrew R. , Zhu Jiaqi , Deland Jonathan T.
Published: January 2022

Category:

Ankle; Hindfoot; Other

Introduction/Purpose:

There is limited documentation of the results of the treatment of advanced progressive collapsing deformity with talar tilt. No article to our knowledge with pre-and post-operative ankle x-rays has more than eight patients and average follow up more than three years.

Methods:

This article presents the results of twenty consecutive patients with medium to long term follow up. All patients had deltoid reconstruction with tendon graft from the talus to the tibia and foot reconstruction to achieve a heel centered under the lower leg, a stable midfoot and a mild to moderately plantarflexed first metatarsal. Patients were followed an average 10.8 years (SD = 4.6, Range 4.6-17) and had standing pre-and post-operative radiographs along with FAOS and PROMIS scores. Radiographs were assessed for talar tilt preoperatively, early postoperatively and at final follow up. Data was analyzed with paired t-tests, Mann Whitney U test, fisher's exact test and univariable linear regression. All p-values are two-sided and statistical significance was evaluated at the 0.05 alpha level.

Results:

Two patients failed the procedure; one had an ankle fusion and the second infection eventually required a BKA. The remaining 18 patients were satisfied with their procedure, maintained significant improvement in outcome scores and talar tilt and required no other procedure on their ankle. The mean talar tilt preoperatively was 10.9 degrees (SD = 3.9) and at final follow up 4.2 degrees (SD = 2.8) (P<0.0001). Initial correction of the talar tilt as documented by early post-operative (mean early follow-up years = 2.2, SD = 1.9) with standing radiograph was maintained within 3 degrees in comparison to final radiographic follow up (Mean=0.56, 95%CI (-0.40, 1.51) P<0.0001).

Conclusion:

Combined deltoid and foot reconstruction, as described, has acceptable results in majority of patients at medium to long term follow up.
Effectiveness of Endoscopic Assisted Repair in Achilles Tendon Ruptures Compared to Percutaneous and Open Repair
Authors: Ceccarini Paolo , Marzano Fabrizio , di Giacomo Lorenzo , Rinonapoli Giuseppe , Caraffa Auro
Published: January 2022

Category:

Arthroscopy; Sports; Trauma

Introduction/Purpose:

The Achilles tendon rupture is the third most common tendon's injury, with an incidence of 16- 18/100000. Various repair's techniques are described, however the best surgical treatment remains controversial. Our purpose was to evaluate the effectiveness of endoscopic assisted repair compared to traditional open repair and percutaneous technique.

Methods:

We carried out a prospective observational study in patient operated in our Orthopedic Department between 2017 and 2019. We enrolled 47 patients (40 M; 7F), with a mean age 42,5 y.o with a mean follow up 32 months (12-60). The patients were divided in 3 groups according to the surgical procedures. Group A included 15 patients underwent to endoscopic assisted repair, Group B: 11 patients with percutaneous repair and group C 21 patients open repair. Demographic data, injury mechanisms, operation's time and technique were recorded. At final f-u complications, functional score (VAS, AOFAS AH, ATRS) were requested. The statistical analysis was performed with the t-student test. IRB approved.

Results:

The 78% of injuries occurred during recreational sport activities, with a majority during football amatorial matches. Operation's time was 42,5 minutes for group A, 33,3 for group B, 33,5 for group C. Among group A, 1 patient developed a DVT. In group B no major complications were reported. In group C a patient suffered from infection with suture insufficiency. Ankle stiffness was reported in 25% of patients in group C. No axonotmesis or neurotmesis of suralis was observed; 16 of patients complained transitory paresthesia in the postoperative. The mean time to return to work's activity was 44,2 days for group A, 35,6 days for group B, and group C 91,1 days, while the mean time to return to drive was in average 72,1 days for group A, 66 days for group B, 92,3 days for group C. ATRS was 79,3 for group A, 87,6 group B and 72,75 group C.

Conclusion:

This technique is safe and achievable with low postoperative pain and complications, early return to activities, and satisfactory functional outcomes. Compared to standard percutane-ous repair, endoscopy-assisted repair of Achilles tendon ruptures may be useful because it ensures precise placement of sutures through the ten-don and real-time visualization of the gap. Further large-scale, randomized and prospective clinical trials must be the subject of future prospective study.
Hallux Valgus Pronation Correction by Scarf Osteotomy: Prospective Case Series with WB-CT Scan
Authors: Chaparro Felipe R. , Ortiz Cristian A. , Espinoza Aravena Raul M. , Pellegrini Manuel J. , Carcuro Giovanni M.
Published: January 2022

Category:

Bunion; Midfoot/Forefoot

Introduction/Purpose:

Hallux valgus is one of the most prevalent foot deformities. Coronal metatarsal rotation (pronation) has been recognized as a key element in hallux valgus deformity and an important prognostic factor for recurrence. New surgical techniques have been developed in order to specifically address pronation deformity but tend to be technically demanding. With the advent of weight bearing CT (WBCT), accurate pronation measurement has improved. Deformity correction by means of metatarsal osteotomies has been an effective way to correct transverse plane deformity but its capacity for pronation correction is not well established. Purpose: Assess transverse and coronal plane rotation deformity correction by WBCT in hallux valgus patients after scarf osteotomy.

Methods:

We prospectively analyzed hallux valgus deformity in patients who underwent Scarf osteotomy for symptomatic hallux valgus with preoperative and at least 3 month postoperative WBCT for comparison. Intermetatarsal angle (IMA), hallux valgus angle (HVA) and alpha angle (AA) for first metatarsal rotation (pronation) was measured by 3 different observers. The intraclass correlation was determined. Pre and postoperative measurement change was established by T-test and Wilcoxon for related samples.

Results:

40 feet in 25 patients were included. The interclass correlation between observers was 0.9 for AA (pronation), 0.92 for IMA and 0.95 for HVA in preoperative evaluation and 0.94 for AA, 0.65 for IMA and 0.82 for HVA in postoperative evaluation. The mean preoperative and postoperative AA of the first metatarsal was 8.9 degrees (range -8.83-24,40, SD 6.8) and 6.3 degrees (range -10.7-28.4, SD 8.3) respectively, resulting in a significant first ray pronation change of -2.5 degrees (P =.006). The media preoperative and postoperative IMA was 13.1 degrees (SD 2.9) and 4.9 degrees (SD 2.0) respectively, demonstrating a significant change (P <.001). The media preoperative and postoperative HVA was 25 degrees (SD 6.7) and 5.9 degrees (SD 4.2) respectively, demonstrating a significant change (P <.001)

Conclusion:

The Scarf osteotomy for hallux valgus deformity has a significant power to correct both transverse and coronal plane (pronation) deformity.
Low Tibial Valgization Osteotomy for More Severe Varus Ankle Arthritis
Authors: Choi Jun Young , Suh Jin Soo
Published: January 2022

Category:

Ankle Arthritis

Introduction/Purpose:

Low tibial valgization osteotomy with medial opening wedge (LTO) is generally indicated for ankle arthritis with a small talar tilt (TT). We addressed the following research questions: the efficacy of LTO for more significant varus ankle arthritis, the effect of additional inframalleolar correction followed by LTO, and the preoperative or operation related factors influencing postoperative TT decrease.

Methods:

We retrospectively reviewed the radiographic and clinical findings of 31 patients with more significant varus ankle arthritis (>=8 degrees) who underwent LTO or LTO plus inframalleolar correction. We grouped the included patients according to combination with inframalleolar correction and postoperative decreased TT. Furthermore, a binary logistic regression analysis was performed to determine the factors influencing postoperative TT decrease.

Results:

Even though the mean TT was unchanged postoperatively (from 12.1 to 9.9 degrees, P =.052), clinical parameters were significantly increased. In the group with concomitant inframalleolar correction, we found that TT was more corrected (3.9 vs 1.8 degrees, P =.023) with a greater lateralization of the talar center and a greater correction of the hindfoot alignment to valgus. The results of the binary logistic regression analysis showed a significant relationship between postoperative decreased TT and preoperative talar center migration (P =.016), hindfoot alignment angle (P =.033), hindfoot moment arm (P =.041), and hindfoot alignment ratio (P =.016).

Conclusion:

LTO in more significant varus ankle arthritis could result in clinical improvement, although TT was not significantly changed. We recommend adding inframalleolar correction after LTO for the patients with more significant varus ankle arthritis.
Considering the Normal Tibial Values of Axial Rotation in Adults for Deformity Correction Osteotomies and Post-Operative Evaluation of Complex Tibial Fractures
Authors: Clarke Gonzalo Fernandez , Morales Eduardo Fuentes , Cataldo Mauricio , Duran Humberto , Pacheco Florencia
Published: January 2022

Category:

Trauma; Other

Introduction/Purpose:

Tibial torsion has been mainly analyzed in pediatric deformities of lower limbs. Nevertheless this parameter has acquired relevancy in treatment of rotational deformities in adult population, that require axial correction. There are few articles that report normal values of tibial torsion, mostly in children, parameter that must be corrected in deformities to improve long term outcomes. Normal values in our population need to be established for preoperative planning and corrections. Our objective is to establish a normality parameter of tibial torsion in adults, that helps us in surgical planning of tibial rotational mal alignment and evaluation of the postoperative axial axis in complex tibial fractures.

Methods:

Descriptive study. We analyzed 18 computed tomography of 18 patients (35 tibias), through the Horos v.3.3.5 program, specifically in the 3D curved-MPR. Inclusion criteria: adult patients, without prior knee, leg or ankle deformities, without post-traumatic sequelae of the limb. Exclusion criteria: severe osteoarthritis of the knee or ankle, presence of osteosynthesis material in the limb, presence of previous osteotomies. Measurements were performed in standardized form previously defined by two foot and ankle orthopedic surgeons. We establish the comparison between both legs of each patient to determine posible variability and measurement interobserver correlations through kappa values.

Results:

All continuous variables are reported as means +- standard deviations. Student t-test was performed for continuous variables depending on the normality of the data distribution. We also performed de paired t-test to identify any significant differences in left and right tibial measurements. Statistical analyses were carried out by an independent statistician using Stata 16 statistical software. Measurements were performed establishing parameters in axial cuts of the tibia and overlapping two images previously determined. 18 patients (35 tibias) were measured, one limb was deleted for severe compromise the tibial plafond by osteoarthritis. 15 male and 3 female patients with an average of 65 years old (62-76 years). Mean external rotation of the distal tibial was 33° (16.1°-49.8°), difference between left and right tibias was in mean values of 1.95°, not being considered statistically significant. Interobserver correlation was reported at 97% in left tibia and 98% in the right, by intraclass correlation.

Conclusion:

Tibial torsion is an important component when correcting tibial axial deformities in adults. Our study shows higher normal values than the ones reported in current literature, but it is important to mention that the best parameter of evaluation is the comparison with the contralateral extremity of each patient.