bluuebunny/crossref_metadata_2025 huggingface dataset:
Lateral Calcaneal Artery: Pertinent Anatomy for Sinus Tarsi Approach and Calcaneal Osteotomy
Authors: Henrikson Karl J , Aydogan Umur
Published: October 2019

Category:

Trauma

Introduction/Purpose:

The lateral calcaneal artery provides critical arterial supply for healing of the extensile lateral approach to the calcaneus. A recent study has shown that preoperative doppler ultrasound showing non-patency of the lateral calcaneal artery is strongly correlated with wound complications when using this approach. Plate and screw fixation of calcaneus fractures through the sinus tarsi approach has gained popularity, including techniques involving percutaneous screw placement into a plate. Avoidance of lateral calcaneal artery injury may be improved with further quantification of its anatomy and associated variation. Finally, while the lateral approach to the calcaneus for osteotomy is routinely performed with minimal wound complications, the relationship of the lateral calcaneal artery to this approach was studied as well.

Methods:

This is a cadaveric anatomic study performed using six fresh frozen cadaver specimens. The specimens were treated with intra-arterial injection of latex and dye. The specimens were first utilized in a separate study in which an orthopedic resident, blinded to the present study, performed a standard, oblique osteotomy of the calcaneal body. The cadavers were then examined for the relationship of the lateral calcaneal artery to the previous dissections. Finally, an extended sinus tarsi approach was made, and the relationship of the lateral calcaneal artery was quantified relative to the posterior facet and the posterior most point of the tuberosity, and relative to screw holes in a percutaneous calcaneal plate.

Results:

Lateral calcaneal artery injury was observed in six out of six cadavers in which calcaneal osteotomy had been performed. The lateral calcaneal artery was encountered when performing the extended sinus tarsi approach at a mean ratio of 0.4 (standard deviation 0.11) of the distance from the posterior facet to the posterior aspect of the tuberosity. It crossed the posterior-most hole in the posterior facet portion of the plate in two cadavers. It also passed within 2 mm of the posterior most hole in the tuberosity portion of the plate in one cadaver.

Conclusion:

Careful dissection is warranted when extending the sinus tarsi approach beyond the posterior facet to preserve the lateral calcaneal artery. Injury is also possible with percutaneous tuberosity screw placement into a plate, and the consequences for sinus tarsi approach healing are unknown. Lateral calcaneal artery injury is difficult to avoid with the traditional lateral approach for calcaneal osteotomy, and while it has no implications for that approach which heals reliably, it indicates that preoperative doppler would be warranted if extensile lateral approach were considered in a patient who has previously undergone calcaneal osteotomy.
Posteromedial Fracture Fragment of the Posterior Malleolar Fracture: A Closer Look
Authors: Heyes Gavin , Vosoughi Amir Reza , Jayatilaka Malwattage Lara Tania , Fischer Benjamin , Molloy Andrew P , Mason Lyndon W
Published: October 2019

Category:

Ankle, Trauma

Introduction/Purpose:

To date, there have been no studies describing the characteristics of posteromedial fragment in the posterior malleolus fracture. The aim of this study was to investigate the variability of posteromedial fracture fragments in trimalleolar fractures to enable better surgical planning.

Methods:

In our department, data on all ankle fractures treated surgically are prospectively collected on our internal database. We collated data from August 2014 to October 2018 for this study. All Mason and Molloy type 2B fractures from our database were identified to analyse the preoperative computed tomography scan. The morphology of the fracture fragment was categorized on whether the fracture appeared to be an intraarticular pilon fragment (i.e. caused by impaction of the talus) or an avulsion extraarticular fracture (i.e. caused by the pull of a ligament). The fracture fragment characteristics were analysed for both the posteromedial and posterolateral fragments.

Results:

The fracture patterns of the posteromedial fragment were investigated in 47 cases (mean age, 46.6; 11 male, 36 female). Morphologically, the fracture could be divided into 2 subtypes, 1) a large pilon type intra-articular fragment (mean of X axis: 32.97 mm, Y: 30.69 mm, Z: 31.74 mm) present in 29 cases with mean Interfragmentary angle of 32.09 and back of tibia angle of 32.66 degrees. This was seen in 25 out of 27 cases with supination injury pattern. 2) A small extra-articular avulsion fragment (mean of X axis: 9.56 mm, Y: 13.22 mm, Z: 11.53 mm) present in 18 cases with mean Interfragmentary angle of 10.97 and back tibia angle of 10.06 degrees. It was seen in 80% of pronation injuries.

Conclusion:

The posteromedial fragment of posterior malleolus fracture can be morphologically subtyped into an avulsion type and pilon type variants. The avulsion type is more common in pronation injuries, likely the result of the pull of the inter-malleolar ligament, and the pilon type is more common in supination injuries, likely the result of the rotating talus impaction. Due to the intra-articular involvement, the pilon type should undergo fixation to achieve articular congruity, unlike the avulsion type whose function is only a secondary syndesmotic stabiliser.
The Use of Percutaneous Screw Fixation without Fracture Site Preparation in the Treatment of 5th Metatarsal Base Non-Union
Authors: Heyes Gavin , Grant Michael , Molloy Andrew P , Mason Lyndon W
Published: October 2019

Category:

Midfoot/Forefoot, Trauma

Introduction/Purpose:

Non-union following a proximal 5th metatarsal fracture can cause considerable pain with high morbidity with loss of work. Although many authors advocate early surgical management of zone 3 injuries (Jones fracture), zone 1 and 2 fractures are generally expected to heal with conservative management. Uncommonly, zone 1 and 2 fractures can develop non- unions. The aim of this study was to evaluate the efficacy of closed intramedullary screw fixation for non-unions of the 5th metatarsal base.

Methods:

We performed a prospective study involving all 5th metatarsal base non-unions treated in our department over 2 years. Only minimally-displaced adult fractures were considered for this study. The fracture pattern was categorised using the Dameron classification (zone 1 – styloid process, zone 2- meta-diaphyseal area, zone 3 – proximal diaphysis). All non-unions were fixed percutaneously under radiographic guidance, without fracture site preparation. Zone 1 injuries were fixed using a 3 mm headless compression screw and zone 2 and 3 with an intramedullary 4 mm screw.

Results:

Out of 30 patients included in this study, a minimum of 6 month clinical follow up was obtained. The average time from injury to treatment was 6 months (range 3-36 months). There were no smokers in this patient cohort. There were 12 zone 1 injuries, 9 zone 2 injuries and 9 zone 3 injuries. All patients achieved union by 3 months post screw fixation, with 29 out of 30 achieving union by 6 weeks. All patients had resolution of symptoms. There were no complications.

Conclusion:

We conclude that percutaneous fixation of 5th metatarsal base non-unions, without fracture site preparation, achieves excellent results. We believe that the screw alters the strain of the fracture, thus promoting fibrous to osseous conversion and therefore union.
Axial Rotational Alignment of Mobile-Bearing Total Ankle Arthroplasty
Authors: Hintermann Beat , Zwicky Lukas , Schweizer Christine , Barg Alexej , Ruiz Roxa
Published: October 2019

Category:

Ankle Arthritis

Introduction/Purpose:

In total ankle arthroplasty (TAA), component malpositioning is a major cause of implant failure, possibly due to the altered force patterns caused by the malpositioning which are then transmitted to the bone-implant interface or neighboring joints during physiological loading. Mobile-bearing TAA with their second interface, may allow the talus to adapt its position based upon the individual anatomy. However, no data exist on the change in component positioning after implantation. It is unclear whether it is the result of initial positioning during implantation or secondary adjustments such as possible soft tissue adaptions. We aimed to determine the relative axial rotation between the talar and tibial components at the end of surgery and after a minimum of 3 years follow-up.

Methods:

The relative rotation between the tibial and talar components was measured in two groups. First, intraoperatively before wound closure, in a consecutive series of 58 patients (60 ankles; age 61.8 [31 to 86] years; females 25, males, 35) who underwent TAA between February and November 2018. A K-wire inserted along the medial border of the tibial component and a rectangular marker positioned at the anterior surface of PE insert were used to determine the angle of rotation. Second, in 48 patients (48 ankles; age 60.2 [31 - 82] years; females, 24; males, 24) out of 1411 patients who underwent TAA between January 2003 and December 2015, and in whom a weight-bearing CT scan was taken for evaluation at 6.3 (range, 3.0 -16.3) years. The medial border of the tibial component and a perpendicular line to the anterior surface of the PE insert were used to determine the angle of rotation.

Results:

The angle of rotation, thus the relative position of the talar component compared to the tibial component, did not differ between the two groups (p = 0.2). While the talus was internally rotated by 1.7 (range, -14.0 - 14.0) degrees at the end of surgery, it was internally rotated by 1.5 (range, -13.0 – 19.5) degrees after a minimum follow-up of 3 years (Figure 1).

Conclusion:

Although there was no significant difference in average axial position measured intraoperatively compared to a 3- years follow-up, there was a wide range of rotational measurements. The possibility of the talar component to find its position as given by individual anatomy may be crucial in TAA to avoid non-physiological joint loads and shear forces which may otherwise result in increased PE wear. Due to the wide range of measurements, our data suggests that axial talar rotation cannot be predicted preoperatively or intraoperatively by surgical techniques that reference the transtibial axis, tibial tuberosity and transmalleolar axis as guidance for tibial component positioning.
InternalBrace Has Biomechanical Properties Comparable to Suture Button but Less Rigid than Screw in Ligamentous Lisfranc Model
Authors: Hopkins Justin , Nguyen Kevin , Heyrani Nasser , Shelton Trevor , Kreulen Christopher , Garcia-Nolen Tanya , Christiansen Blaine A. , Giza Eric
Published: October 2019

Category:

Midfoot/Forefoot, Trauma

Introduction/Purpose:

Lisfranc injuries occurring between the medial cuneiform and base of the 2nd metatarsal require anatomic fixation. Suture button and screws are standard techniques for fixation, but the screw may decrease physiologic motion, whereas suture buttons may cause increased soft tissue irritation and iatrogenic cartilage damage. Potential benefits of the InternalBrace include physiologic motion, decreased iatrogenic damage, collagen ingrowth, limited bony erosion and decreased soft tissue irritation. In light of these potential benefits, no studies have investigated the biomechanical properties of the InternalBrace in a Lisfranc injury model. However, it is unknown whether there is significant difference in the biomechanical properties of the IB compared to the screw, or SB during load to failure, and cyclical loading.

Methods:

Three groups of sawbones were fixed together with either a 3.5 mm screw, SB, or IB, composed of a curved button, fibertape, and 4.75 mm biotenodesis screw. Sawbone constructs were held in a mechanical testing system (Model 809, MTS Systems Corp, Minneapolis MN). The first three groups of 10 were loaded in axial tension at 0.5mm/sec until failure to determine load-displacement data. Yield, stiffness, ultimate strength (US), yield energy, post-yield energy and ultimate strength energy were calculated. Three more groups of 8 constructs were loaded in-vitro at cyclical physiologic loads until displacement of 1.5 mm occurred. Constructs were first loaded for 10,000 cycles at 69 N (estimate for 50% body weight or assisted walking). Surviving specimens were loaded at 138 N (normal walk) for an additional 10,000 cycles and then 207 N (jog) for an additional 10,000 cycles. Displacement was recorded. The biomechanical properties were then compared between groups.

Results:

When loaded in axial tension at 0.5mm/sec until failure, the screw was found to be the stiffest construct (2,240 N/mm), while the InternalBrace (200 N/mm) was stiffer than the suture button (133 N/mm). Qualitatively, the InternalBrace was also found to hold load more consistently and for larger displacement prior to failure when compared to the suture button. Cyclic loading was performed with 10,000 cycles of 69 N, 138 N, and 207 N. The screw had the greatest resistance to fatigue. The InternalBrace maintained stiffness as well or better than the suture button, but the fatigue life was shorter than that of the suture button.

Conclusion:

To our knowledge, the biomechanical properties of the IB have not been compared to screw and SB for ligamentous lisfranc injuries. This study gives valuable information about the mechanical integrity of InternalBrace and supports continued use. However, further studies are warranted before making conclusions regarding early weight bearing.
Review of Use of Amniotic Membrane Allograft in Total Ankle Replacements
Authors: Horn Andrew , Saller Jeremy , Cuttica Daniel , Neufeld Steven
Published: October 2019

Category:

Ankle Arthritis

Introduction/Purpose:

Wound complications after total ankle replacement (TAR) lead to increased postoperative morbidity with lasting consequences. Previous studies demonstrate delayed wound healing in 6.6% to 28% of all TARs. Soft tissue breakdown along the anterior incision can cause exposure of anterior tendons and the implants. In addition, adhesions of the extensor tendons can develop causing significant morbidity. Recent publications advocate for the use of dehydrated human amnion/chorion membrane allograft (dHACM) during closure of anterior ankle incisions during TAR. dHACM is shown to promote increased epithelial cell proliferation, recruitment, and differentiation and reduce the likelihood of tendon adhesions. The goal of this study was to review the use of dHACMs in TARs and to investigate the number and type of postoperative wound complications including extensor tendon adhesions.

Methods:

We retrospectively reviewed 92 TARs performed between April, 2016 through August, 2018 by two board certified, fellowship trained foot and ankle orthopaedic surgeons. A standard anterior approach was done in all cases. All TARs had dHACM graft placed deep to the tibialis anterior and extensor longus tendon and along the extensor retinaculum prior to final closure of the wound. Upon data review, we identified the subset of patients who had anterior wound dehiscence postoperatively requiring an additional procedure(s) for wound coverage. We compared the demographics, medical comorbidities, and operative characteristics of those with and without perioperative wound complications.

Results:

12 patients who underwent TARs sustained wound dehiscence below the subcutaneous tissue and required operative intervention (13%). Of these 12 cases, 5 required bipedical or rotational fasciocutaneous flap coverage (5.4%), 6 required less extensive soft tissue surgery (6.5%) and one case involved a deep periprosthetic infection that resulted in explant and antibiotic spacer placement (1.1%). 6 of the 12 cases required a split thickness skin graft application (6.5%) and 2 cases required tenolysis of extensor tendon adhesions (2.2%). Normal excursion of extensor tendons was seen in 90 patients (97.8%). Except for the one infected ankle, there were no cases with wound dehiscence that communicated with the joint. There were no statistically significant differences in medical comorbidities/operative characteristics between patients with wound complications and those without.

Conclusion:

Wound complications after total ankle replacements often lead to poor long-term outcomes for patients. Our data suggests that the application of the amniotic membrane allograft and its inherent healing potential decreases postoperative tendon adhesions and significant wound dehiscence. This may lead to less deep wound infections that communicate with the joint and may be protective against total ankle replacement failures due to these complications.
Evaluating a Diagnostic Ankle Arthroscopy Scoring System to Assess Competency in Orthopaedic Trainees
Authors: Johnson Jeremiah D. , Schmidtberg Brian , Cheng Christopher , Cote Mark , Geaney Lauren
Published: October 2019

Category:

Arthroscopy

Introduction/Purpose:

While there has been an increasing emphasis on assessing resident competency, little has been published on how to best evaluate competency for ankle arthroscopy. The purpose of this study was to design and validate an objective model for assessing basic ankle arthroscopy knowledge and surgical skills on a cadaveric ankle.

Methods:

The Basic Ankle Arthroscopy Skills Scoring System was adapted from previously validated assessment tools for knee arthroscopy. The scoring system includes (1) an oral questionnaire (0-23 points), (2) a surgical task-specific checklist (0-19 points), and (3) a global surgical skills rating (12-60 points). Ten medical students and twenty-three residents participated. All participants performed a diagnostic ankle arthroscopy on a cadaveric ankle and were assessed by a single observer. Six participants were tested by two evaluators to determine inter-observer reliability.

Results:

There was strong correlation between educational level and scores on the global surgical skills rating scale (r=0.967, p<0.0001), task-specific checklist (r=0.815, p<0.815), and oral questionnaire (r=0.896, p<0.0001). The global surgical skills scores were significantly different over multiple trainee levels but most notably between post graduate year (PGY) 1 and 2 (p<0.01) and between PGY 2 and 3 (p<0.05) [Figure 1a]. Oral questionnaire and task-specific checklists were significantly lower for medical students than PGY1 residents (p<0.001) [Figure 1b-c]. There was significant improvement in the oral questionnaire between senior and junior residents (p<0.05). There was a moderate correlation between number of ankle arthroscopy cases and scores on the global surgical skills score (r=0.7019, p<0.0001). Inter-observer reliability was high for the global surgical skills scores (ICC=0.89).

Conclusion:

The Basic Ankle Arthroscopy Skills Scoring System is a valid measure to objectively assess trainees’ ankle arthroscopy clinical knowledge and surgical skills in a bioskills laboratory. This tool will allow residency programs to evaluate competency and track individual progress over time.
The Role of the Anterior Talofibular Ligament in Acquired Flat Foot Deformity and in the Operative Correction by Lateral Calcaneal Lengthening
Authors: Jud Lukas , Viehöfer Arnd , Singh Sarvpreet , Zimmermann Stefan , Götschi Tobias , Rigling Dominic , Wirth Stephan
Published: October 2019

Category:

Hindfoot

Introduction/Purpose:

Different factors are well known influencing the development of adult acquired flatfoot (AAF) deformity. So far less attention was paid to the lateral ligament complex. The idea that the anterior talofibular ligament (ATFL) probably influences AAF could be obvious concerning its anatomical course. Goal of this study is to assess the influence of ATFL on AAF and on operative AAF correction by lateral calcaneal.

Methods:

We reviewed all patients that undergone lateral calcaneal lengthening in AAF from 01/01/2008 to 07/31/2018 in our clinic. Patients were grouped in patients with intact ATFL and in those with injured ligament. Two independent readers performed assessment of common radiographic flatfoot parameters in preoperative and postoperative radiographs.

Results:

Statistical significant difference between two groups could be observed for preoperative talonavicular uncoverage angle (p=0.018) and talocalcaneal angle (p=0.032), with more severe AAF in patients with injured ATFL. The other common radiographic parameters showed no significant difference, although a tendency to a more severe AAF could be observed within the group with damaged ATFL. No difference could be observed in surgical outcome or consistency after lateral calcaneal lengthening between two groups.

Conclusion:

ATFL seems to take impact in AAF concerning talonavicular uncoverage angle and talocalcaneal angle. In patients undergoing lateral calcaneal lengthening the integrity of the ligament seems not to influence the degree of correction or the consistency of the postoperative result.
Can Combination of Peripheral Nerve Block and Non-opioidal Patient Controlled Analgesia Be an Effective Postoperative Pain Control Method?
Authors: Kang Chan , Lee Gi Soo , Kim Dong Yeol , Lee Jeong-kil , Ahn Ki Jun , Hwang Sung Jin , Seo Gang Won , Kim Yong Hwan , Lee Sang Bum , Song Jae Hwang
Published: October 2019

Category:

Ankle, Pain medicine

Introduction/Purpose:

Even though bone surgery is very painful after operation, there is no established method to control postoperative pain due to efficacy and side effects. Ultrasound-guided peripheral nerve block (PNB) and nonsteroidal anti- inflammatory drugs (NSAIDs) patient controlled analgesia (PCA) can effectively control pain and reduce side effects.

Methods:

We conducted a prospective study of 150 patients over 18 years of age who underwent bone surgery from June 2018 to December 2018. All operations were performed under anesthetic ultrasound-guided PNB and additional PNB was performed to control postoperative pain. Among the 120 patients who participated in the final study, NSAIDs PCA was used in group A (65 patients) and NSAIDs PCA was not used in group B (55 patients) for pain control. Postoperative management except PCA was same in both groups. Pain scores are measured at 6, 12, 18, 24, 36, 48, and 72 hours after the operation and they were compared using visual analogue scale (VAS) pain scores. Survey was done on satisfaction of patients, and their willingness to reconsider same method of pain control when they undergo same surgery next time. Also, we evaluated possible side effects that might happen during process of controlling pain.

Results:

VAS pain score were significantly different only at 24 h postoperatively (p=0.004). In Group A, three patients were prescribed 3 amples of pethidine intramuscular injection as rescue analgesic. In group B, 35 patients were prescribed 50 amples of pethidine and 12 patients of them were received additional 18 amples of ketorolac intramuscular injection as rescue analgesic(p=0.000). In group A, all patients were satisfied with the pain control method, but 5 of the group B patients were dissatisfied (p=0.001). 3 patients responded to severe pain after operation and 2 of them due to postoperative nausea and vomiting (PONV). In group A, there were no patients complaining of PONV, but in group B, 5 patients complained of symptoms (p=0.018), and 3 of them were prescribed additional antiemetics (p=0.093).

Conclusion:

Combined use of ultrasound-guided PNB and NSAIDs PCA seems to be an effective postoperative pain control method in foot and ankle surgery. Because, pain can be effectively controlled and PONV can be reduced.
Intraoperative Ultrasound Guided Percutaneous Repair of Ruptured Achilles Tendon: A Comparative Study with Open Repair
Authors: Kang Chan , Lee Gi Soo , Lee Jeong-kil , Ahn Ki Jun , Hwang Sung Jin , Lee Soong Hyun , Lee Sang Bum , Song Jae Hwang
Published: October 2019

Category:

Ankle, Trauma

Introduction/Purpose:

To compare and analyze the clinical outcomes between ultrasound guided percutaneous repair(USPR) and open repair in ruptured Achilles tendon.

Methods:

We retrospectively analyzed the outcomes between 12 patients with USPR (group A) and 18 patients with open repair (group B), from January 2015 to February 2018. The postoperative clinical evaluations were done by Arner-Lindholm scale, American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, Achilles tendon Total Rupture score (ATRS), visual analogue scale (VAS) for overall satisfaction and cosmetic satisfaction of scar, and starting time of single heel raise. And we evaluated complications.

Results:

There was no statistical difference between two groups in Arner-Lindholm scale, AOFAS score, ATRS, starting time of single heel raise (all p>.05). There was statistically higher overall patient’s satisfaction and cosmetic satisfaction in group A than group B (all p<.05). There were 2 cases of Achilles tendon elongation in group A, and 1 case of re-rupture with deep infection and 1 case of superficial infection in group B.

Conclusion:

The USPR showed not only good clinical outcomes but also high satisfaction and low rate of complications like sural nerve injury. Thus, it is thought that USPR can be considered as an effective surgical treatment options for Achilles tendon ruptures.
Utilization of Over the Counter Analgesics Post-Operatively in Foot and Ankle Surgery
Authors: Khan Shamis , Lam Kenrick , Acebo Joshua , Jain Rishabh , Panchbhavi Vinod
Published: October 2019

Category:

Ankle, Ankle Arthritis, Arthroscopy, Basic Sciences/Biologics, Bunion, Hindfoot, Lesser Toes, Midfoot/Forefoot, Sports, Trauma

Introduction/Purpose:

Managing post-operative pain in patients has become a growing concern given the increasing focus on controlling opioid use. Over the counter (OTC) analgesics such as tylenol and ibuprofen have been shown to be useful adjuncts to post-operative pain regimens and may decrease opioid use. However utilization of these adjuncts may be limited by patient education especially if they are not formally prescribed by the physcian. In this work we aim to identify how often post-operative patients utilize OTC analgesics to supplement their pain control and what are the barriers to usage.

Methods:

All bony foot and ankle procedures performed by a single foot and ankle surgeon were reviewed between the dates of 7/1/2017 - 6/30/2018. Inclusion criteria were age over 18 and not incarcerated. Bony procedures included any osteotomy, fracture fixation, or arthrodesis. This subset of patients were then called and surveyed about their post-operative pain. 114 patients met inclusion criteria.

Results:

42 patients responded to the survey. 27 (64%) of patients did not supplement their pain control with OTC analgesics. The most common reason why (13/27 patients) OTC meds were not used was because pain control on narcotics alone was sufficient. Other reasons included dislike of polypharmacy, not believing they would be efficacious, and not knowing that it is was safe to take them. Total narcotic use between the two groups was higher in the OTC group however (760 mg morphine equivalent in the no OTC group and 1073 mg morphine equivalent in the OTC group, p = 0.25).

Conclusion:

This study highlights the misconception of patients in regards to optimal pain control. The higher absolute narcotic usage in the OTC group may reflect that patients who feel the need to supplement their pain regimen have lower pain tolerance to begin with.
Are Sicker Patients Less Likely to Improve after Ankle Fusion?
Authors: Kohring Jessica M. , Houck Jeffrey R. , Flemister Sam , Ketz John P. , Oh Irvin , Baumhauer Judith F.
Published: October 2019

Category:

Ankle Arthritis

Introduction/Purpose:

The influence of pre-existing medical conditions on post-operative patient reported outcomes are important to consider when selecting and preparing a patient for surgery. The purpose of this study was to determine the impact of medical comorbidities on post-operative physical function and pain in patients undergoing ankle arthrodesis.

Methods:

This was a Global IRB approved retrospective review of 88 consecutive ankle arthrodesis procedures performed from May 2015 to March 2018. Patient reported physical function (PF) and pain interference (PI) were measured as part of the routine care via the PROMIS PF and PI computerized adaptive test. A chart review was performed to determine the Charlson Comorbidities Index (CCI), ASA scores, and demographic data. A multivariate analysis predicting pre- and post-operative PROMIS PF based on PI, ASA score, and CCI was performed. Spearman correlations for CCI, ASA, pre- and post-operative PROMIS T- scores for PF and PI were calculated.

Results:

The ASA score and CCI were not associated with pre-operative PI, although the CCI was predictive of pre-operative physical function (p=0.06), indicating that patients with a higher CCI had lower pre-operative PF. Pre-operative PF and ASA were the best individual predictors of physical function at 6 months post-operatively (r=0.51). At 6 months after undergoing ankle arthrodesis, there was no correlation between CCI and post-operative PROMIS PF and PI outcome T-scores (r=0.02, r=-0.06, respectively), this continued at 1 year post-operatively (r=-0.17, r=0.04, respectively). Demographic data, ASA, CCI, and mean PROMIS T-scores are included in Table 1.

Conclusion:

Sicker patients (ASA score=3) and those with lower pre-operative function recovered more slowly as indicated by lower physical function at 6 months and obtained less physical function benefit from ankle fusion than healthier patients at one year. The results of this study can assist surgeons with risk stratification and educating patients about surgical expectations as pre- operative physical function and ASA score appear to influence post-operative physical function after undergoing ankle arthrodesis.
Matching Patient Expectations after Ankle Fusion Based on Patient Reported Outcome Measures
Authors: Kohring Jessica M. , Houck Jeffrey R. , Flemister Sam , Ketz John P. , Oh Irvin , Baumhauer Judith F.
Published: October 2019

Category:

Ankle Arthritis

Introduction/Purpose:

Much research on outcomes after ankle fusion focuses on gait changes, progression of adjacent joint arthritis, and other clinical measures, but little has been reported on the patient’s perspective. The purpose of this study was to determine the change in physical function and pain after undergoing ankle arthrodesis as determined by patient reported outcomes (PROs).

Methods:

This was a retrospective review of prospectively collected patient reported outcomes data in 88 consecutive ankle arthrodesis procedures performed from May 2015 to March 2018. Patient reported physical function (PF) and pain interference (PI) were measured as part of the routine care via the PROMIS computerized adaptive test at 6 months and 1 year post- operatively. Descriptive data and Spearman correlations were determined for PF and pain at 6 months and 1 year.

Results:

The mean pre-operative PF T-score was 37, less than the pre-determined threshold value of 42, indicating that this cohort was impaired physically and would respond positively to surgical intervention. The mean pre-operative PI T-score was 63 indicating moderate to high baseline pain and greater than the threshold value of 60, indicating that this patient cohort would have decreased pain after surgical intervention. The meaningful clinically important difference (MCID) was achieved for PI at 6 months and 1 year post-operatively (T-score of 4 and 6, respectively). At 6 months and 1 year, there was a moderate inverse correlation between PF and PI (r=-0.49, r=-0.61 respectively) suggesting less pain and more function. Demographic data, mean follow-up time, and mean PROMIS T-scores are seen in Table 1.

Conclusion:

The results of this study indicate that patients can expect to have a clinically meaningful improvement in pain after undergoing ankle fusion. Although patients do improve marginally in physical function, it is most likely the improvement in pain that is the greatest benefit to these patients at one year after ankle arthrodesis. This information is important to share with patients to align patient expectations with surgical results.
Biomechanical Comparison of Hintermann and Evans Osteotomy for Lateral Column Lengthening
Authors: Koury Kimberly , Grasu Beatrice , Stein Benjamin , Abassi Pooyan , Parks Brent , Schon Lew , Guyton Gregory
Published: October 2019

Category:

Hindfoot, Midfoot/Forefoot

Introduction/Purpose:

Both Evans and Hintermann procedures are opening wedge calcaneal osteotomies used for lateral column lengthening in flatfoot reconstruction. Risks of lateral column lengthening include lateral forefoot overload and increased calcaneocuboid (CC) joint pressure. The Evans osteotomy is preformed closer to the CC joint increasing the theoretical risk of higher CC pressures. The Hintermann technique is a more posteriorly located osteotomy developed to avoid destabilization of the anterior calcaneal fragment and subsequent CC joint incongruency. The purpose of this study is to biomechanically compare the Evans and Hintermann osteotomies through analysis of CC joint pressures and forefoot plantar pressures after sequential lengthening of the lateral column.

Methods:

A flatfoot model with radiographic confirmation was created in 10 matched cadaveric specimens which were then randomly selected to undergo either the Evans or Hintermann osteotomy. Specimens were physiologically loaded and the peak pressure of the CC joint and forefoot plantar pressures were measured under the following conditions: (1) intact foot, (2) flatfoot, and (3) sequential lengthening of the lateral column from 6 mm to 14 mm, in 2 mm increments.

Results:

Lateral column lengthening lead to significantly increased pressure across the CC joint in both the Evans and Hintermann specimens. With increasing lateral column length, mean peak CC pressures ranged from 2.9–4.0 and 1.2–2.2 times intact CC pressure for the Evans and Hintermann group, respectively. Normalized mean and normalized peak CC pressures were significantly higher in the Evans osteotomy group compared to the Hintermann group at every level of distraction (see figure). The CC pressures under each testing condition were normalized with respect to the intact foot. Forefoot lateral plantar pressures were significantly increased in specimens corrected with Evans osteotomy at 10 mm and 12 mm of distraction compared to the intact foot.

Conclusion:

The Evans osteotomy lead to significantly higher CC pressures than the Hintermann osteotomy. This data suggests the Hintermann osteotomy for flatfoot reconstruction minimizes increase in CC joint pressures and could reduce the risk of subsequent CC osteoarthritis.
The Difference of In-Shoe Plantar Pressure Between Level Walking and Stair Walking
Authors: Kyung Min Gyu , Lee Chungho , Lee Jae Hee , Cho Yoon Jae , Linying Cao , Lee Dong Yeon
Published: October 2019

Category:

Basic Sciences/Biologics

Introduction/Purpose:

Stair walking is one of common activities of daily living. It is more demanding than level walking and can aggravate discomfort of the foot, such as Morton’s neuroma, plantar fasciitis, Achilles tendinitis, pressure related-ulcer, and etc. Therefore, analysis of increased pressure in specific plantar area at stair walking can be used as a risk assessment of foot discomfort and basic data in the clinical field. The purpose of this study is to analyze plantar pressure distribution and pressure patterns during gait cycle at stair walking compared to level walking.

Methods:

Fourty healthy male adults were recruited. Radiologic measurements and gait analysis were performed to check participants’ normality, and 35 healthy males with 20-28 years old were included. They performed level walking (18 meters walkway), stair (26 steps stair, height:16.7 cm, depth:29.8 cm) ascending, and descending in same type of running shoes. Measurements of in-shoe plantar pressure including peak pressure, pressure-time integral (PTI) were done by Pedar-X system. Only measurements of right steps were used to exclude the effect of the dominant foot. The sole was masked in 7 segments (hallux, 2nd-5th toes, medial forefoot, central forefoot, lateral forefoot, midfoot, heel region) to analyze properly. Percentages were assigned in relation to the size for each mask segment. Statistical analysis was performed using repeated measure ANOVA, and Bonferroni post hoc test was done.

Results:

Mean peak pressures in all regions except for the midfoot were higher during level walking than stair walking. During stair descent, mean peak pressures in all the regions except for the midfoot were generally lower than other types of walking, but it was the highest in the midfoot region. Pressure time integral (PTI) in the medial and central forefoot was higher during stair descent than level walking. PTI in the central and lateral forefoot, and the midfoot was higher when stair ascending than level walking. Pressure time integral (PTI) in the heel region was the highest during level walking, followed by stair ascent, stair descent.

Conclusion:

The risk of aggravation of discomfort in the midfoot area increases when stair descending. The medial region of forefoot bear high pressure load during stair descent, and the lateral region of forefoot and the midfoot region bear high pressure load during stair ascent. This is the first study to show plantar pressure patterns during level and stair walking in the large healthy gender-controlled population. We recommend that patients with pressure related foot lesions in the forefoot or midfoot avoid stair walking.
Individuals with Recurrent Ankle Sprain Demonstrate Postural Instability and Neuromuscular Control Deficits in Unaffected Side
Authors: Lee Jin Hyuck , Choi Gi Won , Jang Woo Young
Published: October 2019

Category:

Ankle, Sports

Introduction/Purpose:

To compare proprioception, postural stability, and neuromuscular control between patients with mechanical laxity and recurrent ankle sprain.

Methods:

Among 86 patients with ankle instability, 45 patients had mechanical laxity (mean age 27.2 ± 7.0 years) and 41 had recurrent ankle sprain (mean age 25.1 ± 9.2 years). Both the affected and unaffected ankles of each patient were evalu- ated. Proprioception and neuromuscular control tests were conducted using an isokinetic machine, and postural stability was tested using a postural stabilometry system.

Results:

Proprioception was not significantly different between the unaffected or affected ankles of the mechanical laxity group compared with those of the recurrent ankle sprain group (n.s). Static and dynamic postural stability and neuromus- cular control were similar in the affected ankles between the two groups (n.s). However, postural stability (static, overall: p = 0.009, anterior– posterior: p = 0.028, medial–lateral: p = 0.022; dynamic, overall: p = 0.012, anterior–posterior: p = 0.004, medial–lateral: p = 0.001) and neuromuscular control (inversion: p = 0.031, eversion: p = 0.039, dorsiflexion: p = 0.029, plantarflexion: p = 0.035) were significantly decreased in the unaffected ankles of the recurrent ankle sprain group compared with those of the mechanical laxity group.

Conclusion:

The unaffected ankles of the recurrent ankle sprain group showed significant decreases in both postural stability and neuromuscular control compared with the mechanical laxity group. Clinicians and therapists should consider unaffected ankle rehabilitation in patients with recurrent ankle sprain to prevent future sprain events.
Ankle and Lower Leg Injuries in Professional Baseball Players
Authors: Lucasti Christopher , Dworkin Myles , Warrender William , Pedowitz David , Winters Brian , Ciccotti Michael
Published: October 2019

Category:

Ankle, Sports, Trauma

Introduction/Purpose:

The purpose of this study was to determine the injury characteristics of ankle and lower leg injuries in professional baseball players during the 2011-2016 seasons by utilizing the Major League Baseball (MLB) injury surveillance system.

Methods:

Our study is a descriptive epidemiological evaluation through a retrospective review from the MLB Health and Injury Tracking System (HITS) since its implementation in 2011. We included any professional baseball player (Major League and Minor League) who was identified as having an ankle or lower leg injury from January 1, 2011 through February 28th, 2017.Over the study period there were a total of 4,756 injuries of which 763 (16.0%) occurred in the Major League and 3,993 (84.0%) occurred in the Minor League.

Results:

The average number of days missed for all players was 27.8 days (+/-141.4 days) with a median of 3 days. From 2011 through 2016 it was estimated that there were 414,912 athlete exposures (AEs) in Major League Baseball and 1,796,607 AEs in the Minor Leagues. Of the 4,756 injuries recorded, 550 (11.6%) took place during the Major League regular season and 3,320 (69.8%) took place during the Minor League regular season. Major League injuries, however, were 1.7 times more likely to require surgery (p < .001). Additionally, rates of injury to the lower leg were stratified by position with infield players experiencing injuries at a 1.6 times greater rate than any other position (p < .001).

Conclusion:

In conclusion, the data from this study represents the only epidemiological study to focus primarily on lower leg injuries in professional baseball players utilizing an injury surveillance system developed by MLB.
The Use of Tranexamic Acid in Total Ankle Arthroplasty
Authors: Luick Laura , Ringus Vytas , Steinmetz Garrett , Falcon Spencer , Tkach Shaun , Hallem Amgad
Published: October 2019

Category:

Ankle Arthritis

Introduction/Purpose:

The number of total ankle arthroplasties (TAA) is on the rise. Complications associated with TAA include need for blood transfusion, deep vein thrombosis, hematoma, infection, and wound complications. Tranexamic acid (TXA) use in the total knee and total hip population has been found to decrease the rate of blood transfusion. The rate of infections and blood transfusions in TAA was reported to be 3.2% and 1.3%, respectively. In calcaneal fractures TXA was found to decrease wound complications. Our goal was to evaluate the use of TXA in the TAA population to see if its use decreases blood loss or wound complications.

Methods:

This is a retrospective review of two patient cohorts operated on by a single surgeon from 2010 to 2016. We compared a group of TAA patients that did not receive TXA versus a subsequent group that received TXA. Patients received 1 g IV TXA before tourniquet was inflated and another 1 g following the release of the tourniquet. Pre-operative hemoglobin and hematocrit levels were compared to postoperative levels. Post-operative complications were compared between the two groups.

Results:

87 patients were included in the study. 35 patients (40%) received TXA. In patients that received TXA, 18 had postoperative hemoglobin levels available. These patients were compared to a control cohort of 52 patients that did not receive TXA. No significant difference existed between the two groups in gender or age (p=0.9; p=0.7 respectively). Mean estimated blood loss was the same between the two groups. Overall postoperative complications, including wound complications, were higher in the TXA group at 26% vs 12% but this was not statistically significant (p-value = 0.086). The preoperative to postoperative change in hemoglobin/hematocrit levels was not statistically significant between groups (p-value = 0.78). There was one transfusion required in the non-TXA group and no transfusions required in the TXA group (p=0.9).

Conclusion:

The use of TXA was not found to provide a beneficial effect in total ankle arthroplasty in either decreasing wound complications or blood loss. Given these results, TXA use might not be cost effective in total ankle arthroplasty as opposed to other total joint arthroplasties. Further higher levels studies with increased number of patients are required to further evaluate TXA effectiveness in TAA.
Psychotropic Medication Use Increases Risk for Poor Outcomes After Hammertoe Correction Surgery
Authors: Maidman Samuel D. , Erwood Amalie A. , Brodsky James , Daoud Yahya , Fantry Amanda , Tenenbaum Shay , Bariteau Jason T.
Published: October 2019

Category:

Lesser Toes

Introduction/Purpose:

Hammertoe deformities are common conditions of the lesser toes, known to affect daily activities and cause pain. Following failure of conservative management, surgical correction of these deformities strives to reduce pain and improve physical function. Currently, 1 in 6 Americans are being treated with psychotropic medications. Baseline mental health issues are known to diminish self-perceived overall health and may hamper recovery following surgery. The aim of this study is to assess the impact of psychotropic medication use on the development of complications and reduction of patient reported outcomes following operative hammertoe correction.

Methods:

Prospectively collected data was reviewed on 116 patients who underwent operative correction of hammertoe deformity following failure of conservative management. Patient demographics, past medical history, and postsurgical complications were recorded from the electronic medical record. Patient-reported outcomes were assessed utilizing preoperative and postoperative Visual Analogue Scale (VAS) and Short Form Health Survey Physical and Mental Component Scores (SF-36 PCS and SF-36 MCS, respectively) with 1-year of follow-up. Data was examined using chi-squared, t-test, and ANOVA analyses.

Results:

17.2% of patient were taking only antidepressants, 10.3% other psychotropic medications, and 8.6% both an antidepressant and another psychotropic medication. Wound infections treated with antibiotics occurred in 12.9%. Mean 1-year improvement in VAS, SF-36 PCS, and SF-36 MCS were 2.8 (SE=0.3), 10.8 (SE = 2.0), and 3.1 (SE = 1.3), respectively. A significant association was found between antidepressant use and postoperative superficial wound infection requiring antibiotics (P=0.049). Antidepressant use was also determined to be significantly associated with lower preoperative and postoperative SF-36 MCS (P=0.0023 and P=0.017, respectively). Other psychotropic medication use was significantly associated with lower preoperative SF- 36 MCS (P=0.030) and PCS (P=0.048) as well as postoperative PCS (P=0.023). However, psychotropic medication use was not associated with any reduction in improvement from pre- to postoperatively.

Conclusion:

Patients receiving psychotropic medications are at an increased risk for developing postoperative infection following hammertoe deformity correction. While these patients at baseline have lower mental and even possible physical component scores, their improvement following hammertoe correction surgery is equivalent to patients not on these medications. Patients treated with psychotropic medications can still benefit from hammertoe correction surgery, but clinicians should recognize the increased risk for complications and expect lower patient-reported outcomes.