bluuebunny/crossref_metadata_2025 huggingface dataset:
Numerical Simulation of the Flow Field and Pollutant Dispersion around a Hill under Different Thermal Stratifications
Authors: Guo Dong-Peng , Zhao Peng , Wan Ran , Yao Ren-Tai , Hu Ji-Min
Published: October 2019

This paper applied a commercial computational fluid dynamics code, STAR-CD, with the renormalization group k–ε turbulence model to simulate the flow and dispersion of contaminants released from a source on the windward side of a hill under different thermal stratifications. In the wake region, the influence of atmospheric stratification on the flow field is inconspicuous under neutral and unstable conditions because of the effect of mechanical disturbance. However, this influence becomes slightly conspicuous under stable conditions. When atmospheric stratification is stable, in the range of z/H < 1.0 (where z is height above the surface and H is height of the hill), the velocity deficits are smaller than those under neutral and unstable conditions. The maximum turbulence kinetic energy (TKE) appears in the wake regions, and the variation in TKE is significantly lower than that under neutral and unstable conditions. When atmospheric stratification is unstable, the vertical and horizontal spread of the plume is slightly greater than that under neutral and stable conditions and the maximum concentration is less than that under neutral conditions. When the Froude number is large (~11; Brunt–Väisälä frequency = 0.52), atmospheric stratification is slightly stable, the structure of flow around the hill is generally similar to that under neutral conditions, and the high-concentration regions are large on the windward side of the hill. Smaller high-concentration regions just appear on the windward side of the hill under unstable conditions. The pollutant concentrations in the wake region of the hill increase as a result of the effect of thermal stability, and the vertical spreading range of the plume along the downwind axis (x axis) is larger than that under neutral and stable conditions.
The Impacts of Automation on Present Weather–Type Observing Capabilities across the Conterminous United States
Authors: Landolt Scott D. , Lave Joshua S. , Jacobson Darcy , Gaydos Andrew , DiVito Stephanie , Porter Daniel
Published: October 2019

In the 1990s, the National Weather Service and the Federal Aviation Administration began deploying the Automated Surface Observing Systems (ASOS). These systems provided the capability to report real-time weather observations, including some types of present weather, as frequently as once every minute. Over 900 of these ASOS stations were installed across the United States, replacing most of the human observers. Despite the benefits offered, many issues were noted, including the inability to discern and report certain precipitation types, particularly drizzle, freezing drizzle, and ice pellets. These and other issues resulted in human observers being retained at roughly 130 ASOS airport locations around the country where high-quality weather observations are essential because of air traffic volume or other factors. The human observers at these locations work in conjunction with the ASOS, manually augmenting the automated weather observations when the ASOS provides erroneous data or when an ASOS observation is missing. To assess the impact of automation on present weather observations, the differences in present weather reports for two decades will be highlighted: 1979–88 (when only human observers reported the present weather observations) and 2005–14 (after the full ASOS network became operational). Comparisons between the decades will be further analyzed to determine the differences at the ASOS locations at which human observers were retained in the later decade, as well as the ASOS locations at which no humans were retained. Both the positive and negative impacts of automation, with an emphasis on aviation impacts, are presented.
The Relationship between Numerical Precision and Forecast Lead Time in the Lorenz’95 System
Authors: Cooper Fenwick C. , Düben Peter D. , Denis Christophe , Dawson Andrew , Ashwin Peter
Published: October 2019

We test the impact of changing numerical precision upon forecasts using the chaotic Lorenz’95 system. We find that in comparison with discretization and numerical rounding errors, the dominant source of errors are the initial condition errors. These initial condition errors introduced into the Lorenz’95 system grow exponentially at a rate according to the leading Lyapunov exponent. Given this information we show that the number of bits necessary to represent the system state can be reduced linearly in time without significantly affecting forecast skill. This is in addition to any initial reduction in precision to that of the initial conditions and also implies the potential to reduce some storage costs. An approach to vary precision locally within simulations, guided by the direction of eigenvectors of the growth and decay of forecast error (the “singular vectors”), did not show a satisfying impact upon forecast skill in relation to cost savings that could be achieved with a uniform reduction of precision. The error in a selection of ECMWF forecasts as a function of the number of bits used to store them indicates that precision might also be reduced in operational systems.
The Editor’s Note: One nation under stress
Authors: Heller Rafael
Published: October 2019

It’s all to the good that so many schools are investing in mindfulness programs, notes Kappan’s editor. But it’s not enough to help students and teachers “manage” their stress. We need to understand and address the conditions that make them stressed out in the first place, including peer competition, racial tensions, overwhelming classroom assignments, and inadequate teacher resources.
All SEL should be trauma-informed
Authors: Pawlo Erica , Lorenzo Ava , Eichert Brian , Elias Maurice J.
Published: October 2019

Critics and supporters have expressed concern that social-emotional learning (SEL) has not been adapted to children suffering from trauma. While SEL has been identified as a mechanism through which trauma-informed schools can be created, this does not make SEL implementation, in and of itself, trauma-informed. Erica Pawlo, Ava Lorenzo, Brian Eichert, and Maurice J. Elias explain why calls for trauma-informed SEL are, in fact, calls for all SEL to be trauma-informed. They discuss how a trauma-informed approach to SEL is related to SEL’s emphasis on school climate, the need to build infrastructure for SEL learning, and the role of emotions in SEL instruction.
Grades versus comments: Research on student feedback
Authors: Guskey Thomas R.
Published: October 2019

Opinions about whether comments, grades, or both are the most effective forms of feedback vary widely among teachers, school leaders, and even grading and assessment consultants. Thomas Guskey maintains that the truth is not as clear-cut as some suggest. He reviews the research, going back to the 1950s, to better understand when certain types of feedback are most useful. He concludes that grades and comments are not, in and of themselves, beneficial to student learning. Effective feedback, whether in the form of grades or comments, must give students a sense of where they are and what they need to do to improve.
Under the Law: Student suicide and school liability
Authors: Underwood Julie
Published: October 2019

When students die by suicide, parents may believe that the school played some role in events leading to the student’s death. Julie Underwood reviews four cases in which schools or school staff faced lawsuits for failing to prevent a student suicide. In general, schools may be deemed legally responsible to student suicides if they created the danger, failed to act reasonably to warn parents, or acted recklessly in carrying out responsibilities to the student.
Career Confidential: Miserable teacher wants to know how to ‘choose happiness’
Authors: Fagell Phyllis L.
Published: October 2019

Phyllis Fagell provides advice to educators. In this column, an unhappy teacher seeks tips for improving her outlook. Another teacher wants help improving his relationship with others in his department, when the department chair is snippy with everyone.
The Anterolateral Structure of the Knee Does Not Affect Anterior and Dynamic Rotatory Stability in Anterior Cruciate Ligament Injury: Quantitative Evaluation With the Electromagnetic Measurement System
Authors: Araki Daisuke , Matsushita Takehiko , Hoshino Yuichi , Nagai Kanto , Nishida Kyohei , Koga Hideyuki , Nakamura Tomomasa , Katakura Mai , Muneta Takeshi , Kuroda Ryosuke
Published: October 2019

Background:

The biomechanical function of the anterolateral structure (ALS), which includes the anterolateral joint capsule and anterolateral ligament (ALL), remains a topic of debate.

Hypothesis:

The ALS contributes to knee joint stability during the Lachman test and the pivot-shift test in anterior cruciate ligament (ACL)–deficient knees.

Study Design:

Controlled laboratory study.

Methods:

Fourteen fresh-frozen hemipelvis lower limbs were used. For 7 specimens, the anterior one-third of the ALS and the residual ALS were cut intra-articularly with a radiofrequency device. Subsequently, the ACL was cut arthroscopically. For the other 7 specimens, the ACL was cut first, followed by the anterior one-third of the ALS and the residual ALS intra-articularly. During the procedures, the iliotibial band (ITB) was kept intact. At each condition, the anterior tibial translation (ATT) during the manual Lachman test and the acceleration of posterior tibial translation (APT) and the posterior tibial translation (PTT) during the manual pivot-shift test were measured quantitatively with an electromagnetic measurement system. The mean values of those parameters were compared among 6 groups (ACL intact, one-third ALS cut, all ALS cut, ACL cut, ACL/one-third ALS cut, and ACL/all ALS cut).

Results:

The mean ATTs during the Lachman test and the mean APTs and PTTs in the ACL-cut conditions (ACL cut, ACL/one-third ALS cut, and ACL/all ALS cut) were significantly larger than those under the ACL-intact conditions (ACL intact, one-third ALS cut, all ALS cut) ( P < .01). However, no statistically significant differences were observed among the intact, one-third ALS–cut, and all ALS–cut conditions, within the ACL-intact or ACL-cut conditions.

Conclusion:

Intra-articular dissection of the ALS did not increase the ATT during the Lachman test or the APT and PTT during the pivot-shift test under the intact condition of the ITB, regardless of the integrity of the ACL. When the ITB is intact, the ALS does not have a significant role in either anterior or dynamic rotatory knee stability, while the ACL does.

Clinical Relevance:

Recent growing interest about ALL reconstruction or ALS augmentation may not have a large role in controlling either anterior or dynamic rotatory knee instability in isolated ACL-deficient knees.
Biomechanical Effects of Additional Anterolateral Structure Reconstruction With Different Femoral Attachment Sites on Anterior Cruciate Ligament Reconstruction
Authors: Katakura Mai , Koga Hideyuki , Nakamura Tomomasa , Araki Daisuke , Nagai Kanto , Nishida Kyohei , Kuroda Ryosuke , Muneta Takeshi
Published: October 2019

Background:

Recently reported anterolateral structure reconstructions (ALSRs) to augment intra-articular anterior cruciate ligament reconstruction (ACLR) use various femoral attachment sites, and their biomechanical effects are still unknown.

Hypothesis:

ALSR concomitant with ACLR would control anterolateral rotational instability better than ACLR alone, and if ALSR had different femoral attachment sites, there would be different effects on its control of anterolateral rotational instability.

Study Design:

Controlled laboratory study.

Methods:

Twelve fresh-frozen hemipelvis lower limbs were included. Anterior tibial translation during the Lachman test and tibial acceleration during the pivot-shift test were measured with a 3-dimensional electromagnetic measurement system in situations with the (1) ACL and ALS intact, (2) ACL and ALS cut, (3) ALSR without ACLR (ALSR alone), (4) ACLR without ALSR (ACLR alone), and (5) ALSR with ACLR. Three femoral attachment sites were used for ALSR: F1, 2 mm anterior and 2 mm distal to the lateral epicondyle; F2, 4 mm posterior and 8 mm proximal to the lateral epicondyle; and F3, over-the-top position for the lateral extra-articular tenodesis. The Steel test and Wilcoxon signed rank test were used for statistical analysis.

Results:

Anterior tibial translation during the Lachman test in the ACL and ALS–cut state was significantly larger than it was in the ACL and ALS–intact state, while its difference disappeared after ACLR. As for the pivot-shift test, additional ALSR with F2 to ACLR significantly decreased the acceleration ( P = .046), although additional ALSR with F1 and F3 showed no significant effect.

Conclusion:

ALSR with the femoral attachment site 4 mm posterior and 8 mm proximal to the lateral epicondyle in addition to ACLR played a role in reducing anterolateral rotational instability the most effectively among the measured attachment sites.

Clinical Relevance:

The present data will contribute to determine the appropriate femoral attachment site for ALSR to better control anterolateral rotational instability after ACL reconstruction.
The Ghost of the Stable Path: Stories of Work-life Change at the ‘End of Career’
Authors: Potter Jesse
Published: October 2019

Accounts of structural changes to the nature of work, employment, and the economy are numerous. Many of these accounts frame the transition from industrial to post-industrial regimes as destabilizing, bringing about a fundamental transformation to work, the economy, and labour markets. These changes are often juxtaposed against the backdrop of permanence. This article argues that while these accounts are romanticized and over-simplistic, ‘traditional’ notions of stability and linear progress remain the rhetorical benchmark for work and career. Drawing on narrative interviews with individuals who have undergone significant career change, the article examines the subjective, intimate, and interpersonal aspects of careers that are unstable, or in transition. These insights highlight how emphasis on structural changes to work and career can overshadow the discursive prevalence of more traditional or linear notions; that the expectation of progress, promotion, and linearity – often associated with ‘traditional’ work, or organizational/industrial career trajectories – remains hegemonic.
Who ‘framed’ Ramchandra Siras? Journalistic discourses of sexual citizenship in India
Authors: Ejaz Khadija , Moscowitz Leigh
Published: October 2019

In 2010, a professor in India was forcibly outed as gay and catapulted into a nationwide debate about LGBTQ rights in India. A textual analysis of prominent Indian English-language newspapers revealed the framing devices journalists used to report the case, unpacking how coverage essentialized gay identity, signified civil rights and citizenship, problematized notions of consent, complicated public/private demarcations of sexuality, and negotiated competing claims of morality. Journalistic discourse inevitably privileged dominant western neoliberal conceptions of sexuality, reducing sexual citizenship to a particular classed and gendered subject at the expense of a more expansive range of alternative sexualities in India.
Model-based clustering for populations of networks
Authors: Signorelli Mirko , Wit Ernst C.
Published: October 2019

Until recently obtaining data on populations of networks was typically rare. However, with the advancement of automatic monitoring devices and the growing social and scientific interest in networks, such data has become more widely available. From sociological experiments involving cognitive social structures to fMRI scans revealing large-scale brain networks of groups of patients, there is a growing awareness that we urgently need tools to analyse populations of networks and particularly to model the variation between networks due to covariates. We propose a model-based clustering method based on mixtures of generalized linear (mixed) models that can be employed to describe the joint distribution of a populations of networks in a parsimonious manner and to identify subpopulations of networks that share certain topological properties of interest (degree distribution, community structure, effect of covariates on the presence of an edge, etc.). Maximum likelihood estimation for the proposed model can be efficiently carried out with an implementation of the EM algorithm. We assess the performance of this method on simulated data and conclude with an example application on advice networks in a small business.
Improving patient diary use in intensive care: A quality improvement report
Authors: Veloso Costa Asya , Padfield Olivia , Elliott Sarah , Hayden Paul
Published: October 2019

Background

Patients surviving critical illness are at risk of developing psychological symptoms that affect quality of life and recovery. Patient diaries may improve psychological outcomes by reducing gaps in memory and contextualising what has happened during admission. Factors including lack of guidelines, lack of awareness and time constraints may lead to poor diary use.

Aims

This quality improvement project aimed to increase diary provision and overall multidisciplinary team engagement with diaries for all patients admitted for over 72 h to an intensive care unit.

Methods

Trialled changes implemented via the ‘Plan-Do-Study-Act’ method included adding alerts to the online patient note system, providing education sessions and introducing a guidance document to facilitate entry completion.

Results

A ‘diary provision’ target of 100% was achieved (from a baseline of 26.1%). Simple changes have proven effective in establishing routine engagement with diaries, and lessons may be used to improve diary systems elsewhere.
Reproducibility and Reliability of Dynamic Ultrasound for Evaluating Tibiofibular Translation in the Sagittal Plane
Authors: Hagemeijer Noortje , Chang Song Ho , Saengsin Jirawat , Waryasz Gregory , Kerkhoffs Gino , DiGiovanni Christopher , Guss Daniel
Published: October 2019

Category:

Ankle

Introduction/Purpose:

Syndesmotic instability, when subtle, is challenging to diagnose and requires visualization of the syndesmosis during an applied stress. Ultrasound is a dynamic, non-invasive diagnostic tool that can do so at the point of care, but its reliability and reproducibility remain unclear. The aim of this study is to evaluate reliability and reproducibility of the dynamic use of ultrasonography, a safe and non-invasive imaging technique, for evaluating tibiofibular translation in the sagittal plane.

Methods:

Patients with no history of injury to either ankle were included in this study. The distal tibiofibular joint was examined using an ultrasound probe placed anteriorly with the patient in supine position, and posteriorly with the patient in prone position. Sagittal fibular translation was simulated by applying an increasing manual force to the fibula in the sagittal plane: 1) in supine position, anterior to posterior (SAP), 2) in prone position, posterior to anterior (PPA), and 3) in prone position, anterior to posterior (PAP) (Figure 1). Two examiners performed the dynamic examination independently to investigate reproducibility of the test. To test for reliability, the relative position of the fibula and tibia were subsequently measured by three observers; with no force application and at maximum force application, defined as the end point at which increased force did not result in additional fibular translation. Interrater reliability was tested using intraclass correlation coefficients (ICC).

Results:

In total 34 ankles among 17 patients were included, of which 24 ankles were male (71%). Mean subject age was 25.0 ± 5 years. Substantial agreement was found for all measurements. Anterior measurements of the distance between the ultrasound probe and the tibia and fibula demonstrated ICC’s of 0.98 and 0.98, respectively. PPA demonstrated ICC’s of 0.99 and 0.99, and PAP ICC’s of 0.99, and 0.99. To test for reproducibility the mean tibiofibular delta values of SAP, PPA, and PAP in neutral, and after maximum force application were compared between exams. Exam 1 vs exam 2: SAPneutral, coef. -0.001, p-value 0.895. PPAneutral, coef. -0.06, p-value 0.076. PAPneutral, coef. -0.01, p-value 0.957. SAPmaxforce, coef. -0.03, p-value 0.365. PAPmaxforce, coef. <-0.01, p-value 0.910, PPAmaxforce, coef. -0.08, p-value 0.028.

Conclusion:

Use of dynamic ultrasound is a reliable and accurate technique for measuring changes in sagittal translation of the tibiofibular joint. Substantial variation between right and left ankles of an individual subject is rare, underscoring the significant utility of the contralateral ankle as a control in the injury setting. This test affords a non-invasive means of diagnosing syndesmotic instability in the sagittal plane.
Acute Retrograde Tibiotalocalcaneal Nailing for Osteoporotic Ankle Fractures in Fragile Patients
Authors: Herrera-Perez Mario , Tejero-Garcia Sergio , Valderrabano Victor
Published: October 2019

Category:

Ankle, Trauma

Introduction/Purpose:

With the rising aging of the population, osteoporotic ankle fractures represent a frequent scenario in daily practice. The coexistence of comorbidities such as poorly controlled diabetes mellitus, vascular insufficiency, and poor condition of the surrounded soft tissues, means that conventional open reduction and internal fixation methods often fail. On the other hand, conservative or orthopaedic treatments in such population are badly tolerated. Our study aims to study the short- term outcome of retrograde tibiotalocalcaneal (TTC) nailing in a selected series of fragile patients.

Methods:

This study included 15 patients who underwent primary retrograde TTC nailing from January 2016 to July 2018. The mean age of the patients was 83,5 years (range, 75 to 88), and the mean follow-up period was 11,5 months (range, 6 to 24 months) with no patient lost to follow-up. All patients but one were diabetic; 2 were non-ambulatory; and 13 walked with walking aids. The authors implemented a primary nailing without addressing tibiotalar or subtalar joint and without using a tourniquet. Complete weight bearing was allowed early as tolerated. Alignment and healing of the fracture were evaluated. American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score were recorded preoperatively and at the final follow-up.

Results:

One of the patients died 8 months after the treatment. Radiographic healing of the fractures were identified in 100% of the cases. In 2 cases, a complete arthrodesis of the ankle joint was achieved by simple nail reaming (Figure 1). No infection or any scarring problems was recorded. Of the 13 patients who walked with difficulty, 4 remained prostrate to a wheelchair, but the rest maintained their previous autonomy. The mean AOFAS score improved from 48 (range, 14 to 71) preoperatively to 71 (range, 44 to 81) postoperatively.

Conclusion:

In the view of these results, we suggest that primary retrograde TTC nailing is a valid option in selected patients with fragility ankle fractures, high comorbidity, poor condition of the soft tissues and with difficulties to walk before the fracture. This option allows an early full weight bearing, avoids complications due to joint off-loading, and achieves acceptable functional results.
The Interosseous Talocalcaneal Ligament Injury Findings in Lateral Ankle Instability with Sinus Tarsi Pain
Authors: Jung Hong-Geun , Lee Jong-won , Song Won Tae
Published: October 2019

Category:

Ankle, Arthroscopy, Sports

Introduction/Purpose:

Lateral ankle instability (LAI) with concomitant sinus tarsi pain is a quite common finding. However, there has been few studies evaluating the subtalar arthroscopic findings for LAI with sinus tarsi pain. The purpose of the study is to evaluate the ST arthroscopic findings of chronic ankle instability with sinus tarsi syndrome. We hypothesized that chronic ankle instability with sinus tarsi pain is highly associated with interosseous talocalcaneal ligament (ITCL) tear which may be the cause for subtalar instability (STI).

Methods:

The study is based on 104 LAI with sinus tarsi pain ankles who had performed lateral ankle ligament stabilization. i.e. Modified Brostrum procedure (MBP), lateral ankle reconstruction (LAR) or subtalar ligament reconstruction (STR) with subtalar arthroscopic (STA) examinations from 2007 to 2018. The STA has been mainly focused on the ITCL injury and debridement of the ITCL tears and synovitis were performed when present. VAS pain score, AOFAS, Karlsson-Peterson functional score were evaluated.

Results:

According to the ST arthrosopic findings, ITCL tears were present in 94% (98/104) of the ankles. Lateral ankle instability (LAI), subtalar instability (STI), and LAI and STI combined were 32%, 30% and 38% respectively. MBP, LAR and STR were performed in 23%, 22% and 56% respectively. VAS pain score was improved from 5.3 to 1.9 (p<0.05). AOFAS score was improved from 67 to 89 (p<0.05), while K-P score improved from 50 to 83 (p<0.05). Sinus tarsi pain was relieved in 65% of the patients.

Conclusion:

We found the high incidence of the ITCL tears (98%) in LAI with sinus tarsi pain, and also diagnosed the STI in 68% of the ankles. We believe that in case of LAI with sinus tarsi pain, ST arthroscopic evaluation for ITCL tears is necessary and the possibility
Influence of Depressive Symptoms on Clinical Outcomes of Total Ankle Arthroplasty
Authors: Kim Tae Yong , Ahn Jungtae , Jeong Bi O
Published: October 2019

Category:

Ankle Arthritis

Introduction/Purpose:

Recently, there have been many reports on the relationship between depression and clinical outcome of knee or hip arthroplasty. However, there is no study on the association between depression and total clinical outcome of total ankle arthroplasty (TAA). This study investigated the relationship between depressive symptoms and clinical outcome after TAA.

Methods:

Forty patients who underwent TAA for end-stage ankle arthritis from July 2014 to July 2017 and were able to follow- up at least 12 months were selected. Depressive symptoms were evaluated using Center for Epidemiologic Studies Depression Scale (CES-D) and Patient Health Questionnaire-9 (PHQ-9). The subjects were divided into Depressive group and Non-depressive group, and the preoperative and postoperative clinical results were compared using a visual analogue scale (VAS), American orthopedic foot and ankle-hindfoot score (AOFAS). The preoperative and postoperative radiological results were also compared using anterior surface angle of distal tibia (TAS), talar tilt of ankle joint (TT), lateral surface angle of distal tibia (TLS), and heel alignment distance (HD).

Results:

The mean age of the patients was 61.6±18.2 years and the average follow-up period was 24.3±7.3 months. 13 subjects were in Depression group and 27 subjects were in Non-depression group. There was no statistical difference in baseline characteristics between the two groups. Additionally, there was no statistical difference in preoperative VAS and AOFAS between the two groups (p>.05). Preoperative and postoperative VAS and AOFAS showed statistically significant improvement in both groups (p<.05). However, the depressive group showed higher result in postoperative VAS than the Non-depressive group significantly (3.1±2.4 vs 1.4±2.3, p<.05). The postoperative AOFAS was also higher in the non-depressive group significantly (89.3±13.4 vs 95.0±8.1, p<.05). Both groups showed improvement in postoperative radiologic index. Preoperative and postoperative radiologic index showed no difference in both groups.

Conclusion:

The clinical outcome after TAA was poor in patients with depressive symptoms when compared to patients without depressive symptoms. Since depressive symptoms is a patient-specific factor that result in less improvement in clinical outcomes after TAA, clinical considerations for depressive symptoms are needed prior to TAA surgery.
Risk Factors for Recurrent Syndesmotic instability after Syndesmotic Screw Fixation in Rotational Ankle Fractures
Authors: Lee Sunghyun , Kwon Hoiyoung
Published: October 2019

Category:

Ankle

Introduction/Purpose:

Rotational ankle fractures often have unstable syndesmotic injuries the require reduction and stabilization. Though multiple studies have focused on methods to assess accurate syndesmotic reduction, fairly high rates of recurrent syndesmosis diastasis were reported. However, there was no study to investigate possible risk factors for syndesmosis widening after surgical fixation. The purpose of this study was to identify the risk factors for recurrent syndesmosis widening after screw fixation. We hypothesized that risk factors for recurrence syndesmosis widening could be identified from patient demographic, intraoperative variables and the extent of the pathologic condition associated with fractures.

Methods:

We performed a retrospective review between 2009 and 2015 of consecutive patients who had sustained rotational ankle fractures with intraoperative evidence of syndesmotic instability requiring syndesmotic reduction and stabilization. The exclusion criteria included syndesmosis screws placed for diabetic neuropathy, skeletal immaturity, tibial pilon fractures, polytrauma, open fracture. Patients were sorted into 2 groups according to the presence of recurrent syndesmosis instability which was defined as a difference in the tibiofibular distance of =2 mm between the injured and uninjured ankles on CT at postoperative 1 year and a positive external rotation test. Furthermore, the statistical analysis by binary logistic regression analysis included the significance of various risk factors including age at surgery, sex, diabetes, smoking, body mass index (BMI), dominant side, type of fracture, associated fracture, initial tibiofibular distance on CT, number and size of screws, cortices. The functional outcomes were assessed with the Foot and Ankle Outcome Score (FAOS).

Results:

A total 126 patients met the study inclusion criteria and underwent analysis. The overall postoperative recurrent instability rate was 25.4% (without recurrence group: 94 patients, recurrence group: 32). It was significantly affected by the BMI (p=0.018; adjusted odds ratio, OR, = 30, 6.21) and concomitant posterior malleolar fracture (p=0.040, adjusted OR 3.31). The other variables were not found to be significant risk factors. There was a significant improvement in the mean clinical scores at one years postoperatively (both p < 0.001), but the mean scores in the group with recurrence were significantly lower than those in the group without recurrence (p=0.021)

Conclusion:

Among the risk factors, obesity and concomitant posterior malleolar fracture were significant risk factors for the recurrent syndesmotic instability after syndesmotic screw fixation. The overall results suggest meticulous attention to concomitant posterior malleolar fracture, especially in obese patients.
Prevalence and Safety of Left-Footed Driving in Right Foot Surgery Patients: A Retrospective Survey and Driving Simulation Study
Authors: McKissack Haley M. , Chodaba Yvonne E. , Bell Tyler R. , Lehtonen Eva J. , Araoye Ibukunoluwa B. , Shah Ashish B. , Stavrinos Despina , Johnson Michael D.
Published: October 2019

Category:

Post-operative Driving

Introduction/Purpose:

For many patients, returning to driving after right foot and ankle surgery is a concern, and it is not uncommon for patients to ask if driving may be performed with their left foot. A paucity of literature exists to guide physician recommendations for return to driving. The purpose of this study is to describe the driving habits of patients after right-sided foot surgery and assess the safety of left foot driving using a driving simulator.

Methods:

Patients who underwent right foot or ankle operations between January 2015 and December 2015 were retrospectively identified. A survey assessing driving habits prior to surgery and during the recovery period was administered via REDCap database through email or telephone. Additionally, simulated driving scenarios were conducted using a driving simulator in 20 patients to compare characteristics of left versus right foot driving.

Results:

Thirty six of 96 (37%) patients who responded to the survey reported driving with the left foot postoperatively. No trends were found associating left foot driving prevalence and socioeconomic status. In driving simulations, patients exceeded the speed limit significantly more (p<0.001) and hit other vehicles more (p<0.026) when driving with the right foot than the left. Time to fully brake and fully release the throttle in response to vehicular hazards were significantly prolonged in left foot driving compared to right (p = 0.019 and p = 0.034, respectively).

Conclusion:

A significant proportion of right foot and ankle surgery patients engaged in left foot driving during postoperative recovery. Driving with the left foot may prolong brake and throttle release times, and is therefore not recommended.
Osteochondral Lesions of the Talus: Few Patients Require Surgery
Authors: Park Seung-Hwan , Seo Sang Gyo , Lee Ho Seong
Published: October 2019

Category:

Ankle, Ankle Arthritis

Introduction/Purpose:

The frequency of progression of osteoarthritis and persistence of symptoms in untreated osteochondral lesion of the talus (OCL) is not well known. We report the outcome of a nonoperative treatment for symptomatic OCL.

Methods:

This study included 142 patients with OCLs from 2003 to 2013. The patients did not undergo immobilization and had no restrictions of physical activities. The mean follow-up time was 6 (3–10) years. Initial MRI and CT confirmed OCL and showed lesion size, location, and stage of the lesion. Progression of osteoarthritis was evaluated by standing radiographs. In 83 patients, CT was performed at the final follow-up for analyses of the lesion size. We surveyed patients for limitations of sports activity, and Visual Analogue Scales (VAS), AOFAS, and SF-36 were assessed.

Results:

No patients had progression of osteoarthritis. The lesion size as determined by CT did not change in 69/83 patients, decreased in 5, and increased in 9. The mean VAS score of the 142 patients decreased from 3.8 to 0.9 (p < 0.001), the mean AOFAS ankle–hindfoot score increased from 86 to 93 (p < 0.001), and the mean SF-36 score increased from 52 to 72 (p < 0.001). Only 9 patients reported limitations of sports activity. The size and location of the lesion did not correlate with any of the outcome scores.

Conclusion:

Nonoperative treatment can be considered a good option for patients with OCL.
Evaluation of the Diagnostic Value of SPECT/CT in Defining Foot and Ankle Pathologies
Authors: Pountos Ippokratis , Charpail Christel , Tellisi Nazzar
Published: October 2019

Category:

Ankle Arthritis, Hindfoot, Midfoot/Forefoot

Introduction/Purpose:

The precise localisation of degenerative or inflammatory pathologies in foot and ankle can be difficult due to the complex anatomy of the joints. MRI plays a vital diagnostic role in these scenarios aiding the diagnosis and preoperative planning. Single-photon emission computed tomography combined with computed tomography (SPECT/CT) is a relatively new imaging technology that combines the sensitivity of nuclear medicine examinations with the anatomical detail of CT. The aim of this study is to analyse the diagnostic effectiveness of SPECT/CT in evaluating foot and ankle pathologies.

Methods:

The authors retrospectively reviewed the medical records of all patients with a foot and/or ankle -related complaint that received SPECT/CT. Exclusion criteria included patients with inadequate follow-up and those that were not initially assessed by a senior foot and ankle surgeon. Collected data included demographic information, results from imaging, clinical progress and outcomes.

Results:

272 included in the study comprised of 156 females and 116 males with a mean age of 52,8 years (range 17-92 years). The acquisition of a SPECT/CT changed the initial diagnosis (from either clinical or radiographs or MRI) in 55% of the cases. SPECT/CT finding correlated with MRI only in 34% of the cases. From the remaining cases SPECT/CT partially correlated with MRI in 26% of cases no correlation was noted in 40%. In regards to patients that undergone a USS or CT guided injection following the finding of a SPECT/CT, 86% reported a transient or long-term improvement in the pain. Overall, the SPECT/CT added confidence to the clinical diagnosis in 89% of the cases while reduced the need of further investigations in 93%.

Conclusion:

SPECT/CT is a valuable tool in depicting foot and ankle pathologies. It was able to provide additional diagnostic value by demonstrating co-existing pathologies as a potential cause of pain. SPECT/CT and MRI exhibit different diagnostic specificity and the limitations of each scan should be taken into consideration. This study strongly supports the use of SPECT/CT as a complementary imaging method to MRI for enhancing diagnostic specificity and outcomes.
Bilateral Sander IV calcaneus fractures: Primary fusion or fixation?
Authors: Shah Rajiv
Published: October 2019

Category:

Trauma

Introduction/Purpose:

Primary subtalar fusion for Sander IV calcaneus fractures was considered to be the standard of care till recent past. Presently debate is on whether to manage Sander IV calcaneus fracture cases with primary subtalar fusion or with open reduction and internal fixation. Bilateral Sander IV calcaneus fractures are seen in cases with fall from height. No study has ever been conducted till date to compare the results of primary fusion of a Sander IV calcaneus fracture on one side and open reduction and internal fixation on another side in cases with bilateral Sander IV calcaneus fractures. We present a study comparing the results of primary fusion versus open reduction and internal fixation for bilateral sander IV calcaneus fracture cases.

Methods:

Twelve cases with bilateral closed Sander IV calcaneus fractures where included in the present study. Cases were operated between four to six weeks by a single surgeon after the appearance of wrinkles. All right sided fractures underwent open reduction and internal fixation with proximal tibia grafting. While all left-sided fractures underwent subtalar fusion with the use of ipsilateral anterior iliac crest grafts. Cases were followed up for 24 months.

Results:

Though operative time was more in the fusion group wound problems were equal in both the groups. Four months of average time to union was the same in both the groups and so was time to return to work. At two years, the AOFAS score was slightly better in the fusion group but it was not statistically significant.

Conclusion:

Primary subtalar fusion is with almost similar results as those with open reduction and internal fixation in bilateral Sander IV at 24 months. Long term follow up with more number of cases is required to prove the benefit of one over other.
Correlation of Health Insurance Provider to Orthopedic Patient Reported Outcome Measures
Authors: Smith Jeremy T. , Abdurrob Abdurrahman
Published: October 2019

Category:

Insurance, Outcomes

Introduction/Purpose:

Previous research has suggested that patient insurance type can influence health-related measures, including patient survival, quality of care, clinical outcomes after certain injuries, and likelihood of returning to work following orthopedic injury. Patient reported outcome measures (PROMs) are a way of evaluating patients’ self-perception of health and function. The aim of this study is to determine if insurance type is associated with trends in PROMs scores in a general population of orthopaedic foot and ankle patients.

Methods:

We retrospectively reviewed the electronic medical records of 14,447 adult foot and ankle patients who had completed PROMs questionnaires from 2015 to 2017. We evaluated the following validated PROMs: Foot and Ankle Ability Measure (FAAM), PROMIS Global Short Form (both Physical and Mental Sub-scores), and PROMIS Physical Function Short Form 10A. Descriptive analyses, ANOVA, and Tukey HSD post-hoc analyses were conducted to evaluate trends of PROMs scores relative to insurance type.

Results:

The mean age of patients was 54.6 years, with 64.8% of patients being female (Table 1). Patients with Workers Comp/Motor Vehicle insurance (n=61) had the lowest mean FAAM, PROMIS Global – Physical Score, and Physical Function Short Form 10A score. Medicaid patients (n=836) had the lowest mean PROMIS Global – Mental Scores. Patients with Commercial insurance (n=9088) consistently had the highest PROMs scores (Table 1). Statistical analyses showed the scores of patients with Commercial insurance to be statistically significantly higher than the pooled scores of all other patients (Table 2). Significantly poorer scores were also seen for Workers Comp/Motor Vehicle as compared to the rest of the cohort (Table 2).

Conclusion:

This analysis reveals differences in PROMs amongst patients with different health insurance providers. In general, patients with Workers Comp/Motor Vehicle and Medicaid had poorer outcomes scores than those with Medicare or Commercial insurance. These differences were statistically significant and exceed published MCIDs for FAAM and PROMIS PF 10A. While further research is required, as we did not control for different diagnoses, we believe this is useful information in characterizing how patient insurance type can impact patient reported outcomes.
Single-Nucleotide Polymorphisms in the P2x7 Receptor Gene are Associated with Bone Mineral Density and Ankle Fractures
Authors: Stéfani Kelly Cristina , Fernandes Túlio Diniz
Published: October 2019

Category:

Ankle, Basic Sciences/Biologics, Trauma, Osteoporosis

Introduction/Purpose:

The objective of this study is to determine the associations among genetic variations in the P2X7 receptor gene, decreased bone mineral density (BMD), and the risk of osteoporosis in patients older than 50 years with ankle fractures.

Methods:

A Level-1 diagnostic study was conducted. Patients over 50 years of age with ankle fractures who had undergone surgical treatment were divided into two groups following the result of a bone densitometry: a study group with osteopenia (bone mineral density T score between -1 and -2.5) or osteoporosis (bone mineral density T score = -2.5) and the control group with normal values (bone mineral density T score = -1). Exclusion criteria were alterations that led to secondary osteoporosis. Patients were genotyped for 15 nonsynonymous single nucleotide polymorphisms (SNPs) within the P2X7 receptor (numbered from 1 to 15) obtained from saliva. We evaluated 121 patients with ankle fractures, 56 being from the control group, and 65 from the study group. All patients were sedentary, did not take any medication for the treatment of osteoporosis, did not smoke, and had suffered a low-impact trauma.

Results:

The grouped assessment of the SNP alterations showed that if a gene has three or more SNP variants (36.4% of the 121 patients), out of the 15 possibilities, it is altered with clinical repercussions related to the loss or gain of the function of the gene. In evaluating the SNP alterations individually, the results suggest that: SNPs 1,4,14, and 15 are loss of function variants; SNPs 5 and 10 are described as loss of function variants; however, they have no influence on our study population; SNPs 11 and 13 are loss of function variants and not gain of function function as is described in the literature; and SNP 12 was associated with a loss of function in our population.

Conclusion:

In conclusion, we demonstrate that functional polymorphisms in P2X7 are associated with BMD and with an increased risk of ankle fractures. The limitations of our study are its focus on non-synonymous polymorphisms, which do not cover all genetic variations in P2X7, and its small sample size compared to the international literature. One of this study’s strengths is the fact it is the first to evaluate P2X7 in the Brazilian population.
High Prevalence of Degenerative Changes at the Metatarsal Head Sesamoid Articulation Found During Hallux Valgus Correction Surgery
Authors: Tsai Justin , Daniel Joseph N. , McDonald Elizabeth , Rogero Ryan , Nicholson Kristen , Shakked Rachel J. , Pedowitz David I. , Raikin Steven M.
Published: October 2019

Category:

Bunion

Introduction/Purpose:

Despite absence of complications and a restoration of normal hallux alignment, some patients have suboptimal outcomes from hallux valgus correction surgery. One risk factor for persistent pain may be the presence of arthritic changes at the metatarsal head articulation with the sesamoids, an area not easily assessed with standard preoperative radiographs. In this study, we prospectively evaluated the metatarsal head for degenerative changes during hallux valgus correction surgery and identified preoperative risk factors associated with these changes.

Methods:

We prospectively evaluated 200 feet in 196 patients who underwent hallux valgus surgery intraoperatively for the pattern and severity of arthritic changes at the metatarsal head. Intraoperatively, the first metatarsophalangeal and sesamoid metatarsal joint were assessed for arthritic changes. The articular surface of the metatarsal head was divided into zones 1-6 (Figure 1). Cartilage loss in each zone was graded from 0-2 based on a novel grading system, with a score of 0 representing the absence of arthritis. A score of 1 indicated fissures without exposed bone, and a score of 2 represented degenerative changes to the level of exposed bone. Mann-Whitney U testing was implemented to compare differences in arthritic scores between preoperative deformity groups. Spearman’s correlation test was used to determine the association between age and preoperative deformity with the severity of degenerative changes.

Results:

One-hundred two out of 200 feet (51%) assessed had severe arthritic changes at the plantar medial aspect of the metatarsal head, and 40% (80/200) at the plantar lateral aspect. The mean preoperative hallux valgus and intermetatarsal angles were 29.6 ± 8.5 (range, 9.8-55.3) and 14.2 ± 3.3 (range, 6.6-25.9), respectively. Those presenting with an intermetatarsal angle (IMA) >/= 14 degrees had a significantly higher level of arthritis when compared to those presenting with an IMA < 14 degrees (p < 0.001). No difference in arthritis scores was found for HVA. Age was found to have a strong and significant (p < 0.001) correlation with zone 5, zone 6, total plantar zone, and total arthritis scores.

Conclusion:

The high prevalence of arthritic changes at the metatarsal head articulation with the sesamoids may be partially responsible for suboptimal outcome following hallux valgus correction surgery. Since these changes were associated with greater age and preoperative deformity, operating earlier in the pathology of hallux valgus may be of benefit.