bluuebunny/crossref_metadata_2025 huggingface dataset:
Does the Presence of Pes Planus Deformity Increase Recurrence of Hallux Valgus Deformity Following Surgery?
Authors: Heyes Gavin , Swanton Eric , Mason Lyndon , Molloy Andrew P.
Published: October 2019

Category:

Bunion

Introduction/Purpose:

Factors linked with increased risk of developing Hallux Valgus include; shod footwear, genetic factors, metatarsal morphology, ligamentous laxity and Pes Planus. With regards to Pes planus, it has been suggested that the loss of the medial longitudinal arch in Pes Planus increases Hallux plantar medial pressures and drives deformity during heel rise. There is little in the literature regarding whether Pes Planus is associated with increased recurrence rates. Given this is a potentially modifiable risk factor we believe the risk of recurrence should be studied. This paper reports the results of a retrospective study following up 183 consecutive Hallux valgus cases. The primary objective is to evaluate whether pes planus is associated with increased recurrence following treatment.

Methods:

Retrospective review of consecutively treated patients from 07/03/2008 to 05/12/2017. Patients were typically followed up for six to twelve months depending on any additional factors that require follow up. X-rays were performed routinely at six weeks, three months and many had x-rays at six and/or 12 months for additional pathology. We examined radiological markers including Sesamoid location (using the Hardy and Clapham Classification), Hallux Valgus Angle (HVA), Intermetatarsal Angle, Meary’s angle and Talonavicular uncovering. 183 cases were reviewed, 12 were excluded due to previously amputated second toes, Hallux Varus, revision surgery and only 6 weeks follow up. This left 171 cases of which 75 had Pes Planus (Meary’s angle < -4°).

Results:

Table 1 describes the preoperative HVAs we encountered and the correction achieved along with frequencies. Postoperative measurements were taken off weight bearing x-rays. The incidence of recurrent HVA > 15° was significantly higher in those with Meary’s angle < - 4° (Chi-Sq 22.6 P-value 0.000002). Those with a Meary’s angle -20° to -10° had a significantly higher rate of recurrence than ones measuring -10° to -4° (Chi-Sq 9.7 P-value 0.0018 There was no difference in progression of recurrent deformity between those initially corrected to HVA < 15° (Chi-Sq 0.26 P- value 0.61) and those not. Multiple regression analysis revealed there was no meaningful association with sesamoid location or pes planus with recurrence of Hallux Valgus deformity.

Conclusion:

Our results demonstrate a link between Preoperative Pes Planus deformity and increased recurrence rates of Hallux Valgus deformity following surgery. Consideration of correction of pes planus and appropriate consent of recurrence rates should therefore be undertaken in treatment of hallux valgus in the presence of pes planus
Posterior Approaches to the Ankle: An Analysis of 3 Approaches for Access to the Posterior Distal Tibia
Authors: Heyes Gavin , Philpott Matthew , Jayatilaka Lara , Molloy Andrew P. , Mason Lyndon W
Published: October 2019

Category:

Ankle, Trauma

Introduction/Purpose:

With the increase in the use of CT scanning and fragment specific fixation for complex ankle fractures, utilisation of multiple surgical approaches has increased. The posterolateral approach has been advocated by many, however in our experience, a large proportion of these fractures are not attainable by this approach. Our aim in this study was to analyse three posterior ankle approaches to find their use and efficacy in accessing the posterior tibia in the fixation of posterior malleolar fractures.

Methods:

We examined 5 fresh frozen cadaveric lower limbs. Three posterior ankle approaches (posterolateral (PL), posteromedial (PM) and medial posteromedial (MPM) approaches were performed, using a consistent repeatable incision of 7 cm extended proximal from the palpable distal extent of the medial malleolus. In both the PL and PM approaches, the flexor hallucis longus (FHL) was taken medially. In the MPM approach, the access was anterior to tibialis posterior (TP). K-wires were then placed parallel to one another at the 4 extremities of the approach. The ankles were imaged using an image intensifier and the distances measured. Our database of 172 consecutively treated posterior malleolar fractures in our department, was used to analyse the fracture fragment size and compare these fracture patterns to the approaches. The fractures were categorised using the Mason and Molloy classification. Only type 2 and 3 fractures were included, leaving 101 in the study.

Results:

On radiographic analysis, the type 2B and type 3 fractures incorporate 100% and 83% of the posterior width of the tibia respectively. Considering the PL approach only allows access to 40% of the posterior width of the tibia, another approach is required for these fracture patterns. Only 65% of fractures could be adequately exposed using the PL incision. In comparison, 78% of fractures could be exposed using the PM incision. The MPM incision gave the largest area for access to the posterior tibia, however it did not allow access to the constant posterolateral fragment. Only 35% of patients had posteromedial fractures that could be dealt with using the MPM incision, thus its usage is primarily as a supplementary incision, in conjunction with the PL incision.

Conclusion:

We conclude that the most commonly used approach (the PL approach) gives the least amount of access to the posterior tibia. In comparison to fracture fragment size, almost half of fractures would not be adequately exposed through the PL approach, and if fixing such fractures the surgeon should be comfortable with multiple approaches.
A Prospective Randomized Controlled Trial Comparing Physical Therapy with Independent Home Stretching for Plantar Fasciitis
Authors: Kaiser Philip B. , Crawford Alexander M. , Bluman Eric M. , Smith Jeremy T. , Chiodo Christopher P.
Published: October 2019

Category:

Hindfoot, Heel pain, plantar fascia

Introduction/Purpose:

Physical therapy (PT) is an effective treatment modality for patients with plantar fasciitis (PF) however it is unclear how this compares to a home-based plantar fascia-stretching (HS) protocol. We hypothesized there would be no difference in pain scores or clinical outcomes in patients treated with formal PT compared to those who performed HS.

Methods:

Fifty-seven patients with PF for at least three months were enrolled in a prospective randomized controlled trial comparing formal PT, using any and all modalities deemed clinically necessary, to a standardized HS protocol. Pain scores using a visual analog scale (VAS) and clinical patient reported outcomes including the Foot and Ankle Ability Measures (FAAM) and the Short Form (36) Health Survey (SF-36) were recorded and analyzed at 6 weeks, 3 months, 6 months, and 1 year after treatment commenced.

Results:

There were no significant differences in pain scores (VAS) or patient reported outcomes (FAAM and SF-36) at any follow-up time point between patient groups. At 6-months pain scores had improved in both the HS group (35% decrease, p<0.001) and PT group (26% decrease, p=0.002) relative to baseline without a significant intergroup difference (p=0.32). FAAM- activities of daily living (ADL) scores improved 13.0% (p=0.005) in the HS group and 21.3% (p<0.001) in the PT group at 6-months relative to baseline without a significant intergroup difference (p=0.84). The Physical Component Summary (PCS) Scores of the SF- 36 demonstrated improvement at the six week, three month, and one year time points in both groups.

Conclusion:

A home-based stretching therapy program demonstrated equivalent improvements in pain scores and clinical outcomes compared to formal PT in the treatment of PF. Most patients with PF who perform daily plantar fascia stretching exercises can expect substantial durable clinical improvement in their symptoms.
The Augmentation Technique for Anatomical Reduction of Shortened Lateral Ligament Complex in Modified Broström Procedure
Authors: Kang Chan , Lee Gi Soo , Lee Jeong-kil , Ahn Ki Jun , Hwang Sung Jin , Park Young Cheol , Chung Hyung Jin , Song Jae Hwang
Published: October 2019

Category:

Ankle, Sports

Introduction/Purpose:

The modified Broström procedure(MBP) is clinically standard surgical treatment of lateral ankle instability with or without subfibular ossicle. But if there is a large ossicle or distal malposition of lateral ligament complex(LLC), it can result in a lack of remnant ligamentous tissue and leave gap that may not be approximated. Thus, we have proposed an augmentation technique for anatomical reduction of shortened LLC in MBP and evaluated radiologic and clinical findings.

Methods:

From December 2013 to February 2018, fifty two of fifty six patients who had shortened LLC treated with the augmentation technique with MBP using absorbable suture material. LLC(anterior talofibular ligament(ATFL) and calcaneofibular ligament(CFL)) was exposed after inferior extensor retinaculum(IER) was incised. Then, we identified shortened LLC. Then, we incised just distal part of connecting soft tissue of ATFL and CFL additionally for reduction to anatomic footprint. After confirmation of reduction, 4 or 5 bone tunnels were made and deep fiber of LLC was repaired tightly with foot in neutral dorsiflexion and 5° eversion by using horizontal mattress and simple stitch. Then, superficial fiber with capsule of LLC was repaired by priorly tied suture without cutting. Finally, IER was reinforced.

Results:

Mean AOFAS scores improved from 59.2 to 91.4 at final follow-up. Mean Karlsson scores also improved from 61.3 to 89.5 at final follow-up. Mean talar tilt angles were 13.4° preoperatively and 5.8° postoperatively. Mean anterior talar translations were 9.1 mm preoperatively and 5.7 mm postoperatively. There was significant improvement between preoperative & final follow- up in all parameters (all p < .05). During follow up, no clinical symptom like experience of instability or irritation of skin were encountered after surgery, and no patient underwent revision lateral ligament surgery.

Conclusion:

Augmentation technique of LLC flap in MBP enabled anatomical reduction of shortened LLC to footprint, and provided good clinical and radiographic outcomes. If further comparative and mechanical study is supported, this technique would be a good treatment option.
The Effect of Medial Displacement Calcaneal Osteotomy on Tarsal Tunnel Volume
Authors: Kim Jae Young , Chun Dong-II , Cho Jaeho , Yi Young
Published: October 2019

Category:

Hindfoot

Introduction/Purpose:

Tarsal tunnel volume is affected by position of the foot and the alignment of the ankle. Although medial displacement calcaneal osteotomy (MDCO) significantly alters the alignment of the hindfoot, the change of tarsal tunnel volume after this procedure has not yet been well documented. Therefore, authors investigated the volumetric change of tarsal tunnel after MDCO using Computed Tomography (CT) scan.

Methods:

This retrospective study involved 101 feet of 91 patients who underwent a MDCO at our institution from March 2016 to December 2018. We compared the tarsal tunnel volume from the preoperative and postoperative CT scan images under following protocols. On a sagittal scout image, the oblique axial plane was drawn parallel to the long axis of the calcaneus using talonavicular joint as a landmark. Serial oblique axial images were displayed using PACS (PathSpeed, GE Healthcare, Chicago, IL, USA) with both the soft tissue and the bone window settings. The volume of tarsal tunnel was evaluated from just distal to the tip of medial malleolus anterior colliculus to distance of 3 cm distal using 10 consecutive images by drawing the border of tarsal tunnel. The volume was calculated by adding 10 cross-sectional areas and then multiplying by 3 mm corresponding to slice thickness.

Results:

The mean preoperative and postoperative tarsal tunnel volume were 12229 mm3 (SD, 1842 mm3) and 12762 mm3 (SD, 1803 mm3), respectively. There was 4.6% (SD, 3.4%) of volume increase after MDCO (p <0.001). Results indicated high inter- and intraobserver reliability coefficients (r = 0.97, r = 0.98, respectively).

Conclusion:

MDCO increased the volume of tarsal tunnel. This finding might support clinicians performing MDCO as a conjunctive surgical option in treating patients with tarsal tunnel syndrome.
Result of Short Leg Cast or Short Leg Splint for Chronic Open Wound over Lateral Malleolus
Authors: Kim Ki Chun , Lee Kyung Tai , Young Ki-Won , Sung Hoon , Kim Jin Soo , Lee Young Koo , Park Young Uk , Lee Hong-Seop , Kim Jae Woo , Jegal Hyuk
Published: October 2019

Category:

Ankle

Introduction/Purpose:

Chronic open wound(COW) over lateral malleolus(LM) is hard to manage for high recurrence rate. Characteristic bone to skin structure of LM is vulnerable to pressure or shear force causing bursitis or ulcer leading to bone exposure in some cases. In resting state, ankle is slightly plantar flexed and varus position, so the skin over LM receives tension. This unfavorable condition for vascularity and pressure endurance could be worse when patients have sensory loss, vascular impairment or paraplegia. We hypothesized short leg cast (SLC) or short leg splint (SLS) keeping ankle in neutral position relieves skin tension and reverse this unfavorable condition leading to wound healing.

Methods:

Between July, 2014 and November, 2018, fifteen patients with COW over LM were included. Infection was accompanied by twelve. Seven patients were diagnosed diabetic foot. Seven patients could not move their affected limb actively due to paraplegia or weakness. Firstly, Vascular evaluation and management was done for ischemic patients. For all patients, repeated debridement for necrotic and infected tissue was done at intervals of two or three days until the viable wound was present. Negative pressure wound therapy(NPWT) was added in non-viable wound cases. SLC or SLS followed these procedures till wound healing. Removable SLS was kept for the patients who could not control lower limb such as paraplegia or weakness after wound healing.

Results:

Wound healing was achieved in 14 cases(93.3%). It took average 51.4±40.2 days for wound healing. One patient did not succeed in wound healing resulting in below knee amputation because of infection aggravation. There was no recurrence in all wound healed patients.

Conclusion:

Repetitive COW over LM could be healed using SLC or SLS and the healed wound kept its state with removable SLS. It is considered that conservative treatment for Repetitive COW over LM with SLC or SLS is another favorable treatment option.
Novel Pathologic-Scoring for Charcot Arthropathy with Intraneural Observations
Authors: King Jesse , Murie Ben , Fanburg-Smith Julie , Stauch Chris , Walley Kempland , Flemming Donald , Aynardi Michael
Published: October 2019

Category:

Diabetes, Hindfoot, Midfoot/Forefoot

Introduction/Purpose:

Charcot arthropathy is a destructive joint disorder in patients with longstanding neuropathy, commonly related to Type II diabetes (T2DM). The diagnosis is historically classified via the radiologic Eichenholtz staging system (E-score). The purpose of this study is to examine histopathologic features and develop a correlative pathologic score for Charcot neuroarthropathy.

Methods:

Patients undergoing lower limb surgery with a clinical diagnosis of midfoot-ankle Charcot neuroarthropathy were included for study. Clinical data, radiology, E-score (1-3), and surgical pathology specimens were reviewed to evaluate skin, adipose, vessel, skeletal muscle, nerve, bone, and bone fragments embedded in synovium. Charcot pathology-score 1 (P-score, CPSI) = large bone fragments (> half 40x hpf objective) without host histiocytic response. CPSII = mixed large and small bone fragments with/without host histiocytic response, CPSIII = small to minute spicules to almost complete resorption/absence of bone fragments with histiocytic/fibrosis-reactive response, were scored by the authors in a blinded fashion.

Results:

Forty-two patients (32 males and 10 females) were included in analyses with a mean age of 59.9 years (median age: 60, range 28-83). Clinical risk factors for Charcot included T2DM and longstanding neuropathy. Elevated HbA1C, E-Score, preoperative American Society of Anesthesia score, and Charlson comorbidity index were predictors of amputation. Majority of pathologic specimens examined had superficial ischemic ulceration, dermal fibrosis, cellulitis, medial hypertrophy, atherosclerosis, skeletal muscle atrophy, and nerve hypertrophy with intraneural edema and perineural fibrosis. Osteomyelitis was present in >70%. P-scores CPSI = 6%, CPSII = 44%, CPSIII = 50% correlate with E-scores in 98% of cases without interobserver variability. Minor difference from E-score to P-score (2%) was due to sampling. Novel neuropathy change includes observation of intraneural vasculopathy (arteriolosclerosis) in evaluable nerves.

Conclusion:

CPS is reliable and reproducible and can be performed with adequate synovial sampling. Charcot progresses from large bone fragments in synovium to mixed size with histiocytic response, and final small/resorbed fragments with marked host response/fibrosis. Intraneural vasculopathy likely plays a role in Charcot. Charcot pathology-score (P-score) strongly correlates with clinicoradiologic Eichenholtz-score (E-score).
Retrospective Analysis of the Reverdin-Green Osteotomy for Hallux Rigidus in the Presence of Metatarsus Primus Elevatus
Authors: Krause Fabian , Rueger Tobias , Alpuerto Bernadino
Published: October 2019

Category:

Bunion

Introduction/Purpose:

Hallux rigidus outlines progressive degenerative changes in the 1st metatarsophalangeal joint (MTP I) by several causative factors, i.e. metatarsus primus elevatus. It often leads to disability, difficulties wearing shoes, and gait abnormalities. Despite numerous non-operative and surgical treatments for hallux rigidus reported in the literature, a gold standard treatment protocol for the disease is still missing. Thus, this study investigates the clinical and radiographic outcomes of the commonly used Reverdin-Green Osteotomy (RGO) by validated outcome measurements.

Methods:

We retrospectively reviewed medical records of ten patients (12 feet) that were diagnosed with hallux rigidus in the presence of metatarsus primus elevatus (MPE) and underwent RGO procedure. Primary study objective was the clinical outcomes of the RGO procedure, among others measured by validated FFI and SF12 scores. Secondary study objective was to determine any progression of MTP1 arthritis after the procedure.

Results:

The average 1st MTP dorsiflexion had improved from 39° (SD ± 21°) to 54° (SD ± 17°). The average value of the AOFAS, hallux metatarsophalangeal-interphalangeal subscale was 81 points (±9.5). The FFI, revealed an average score of 27.5 (± 18.7). The VAS-FA was 70.5 (± 19) for pain, 77.7 (± 23) for function. In the SF-12 survey, the general physical health score was 73 (± 19) and the general mental health score 76 (± 14) on average. Only one patient demonstrated a radiological progression of MTP joint degeneration from grade 2 to grade 3. In all other cases, arthritis grading remained stable. A MPE of equal or more than 5 mm was present (mean 6.9, SD ± 1.7) in all feet.

Conclusion:

In the presence of supposedly causative MPE, the RGO seems to be a reasonable option. To determine the most appropriate surgical solution for treatment of specific stages of hallux rigidus, long-term follow-up and further studies are necessary in the future.
Evaluation of Anatomic Relationship between Sural Nerve and Instrumentation during Mini-open Achilles Tendon Repair: A Cadaveric Study
Authors: Krautmann Kurt M. , Stewart Gary W.
Published: October 2019

Category:

Sports

Introduction/Purpose:

The Achilles tendon is one of the most commonly ruptured tendons in the adult population, and there is still no consensus on optimal treatment. While surgical repair may result in a lower re-rupture rate and quicker functional return, it also comes with risk of wound complications and sural nerve injury. If surgical repair is chosen, the surgeon may choose a traditional open procedure, a mini-open technique, or a percutaneous approach. The main advantage of the mini open repair method is the reduced wound complications that comes with a much smaller incision, while still maintaining similar re-rupture rates. The purpose of this study was to determine the relationship of the sural nerve to the Arthrex PARS jig and repair sutures.

Methods:

Cadaveric dissection was performed on 10 unpaired above knee amputation specimens. After severing the Achilles tendon and inserting the jig for a mini open repair, the sural nerve was dissected out to determine the rate of nerve puncture by the passed sutures. The jig was then removed to determine if the nerve was bound by the passing sutures or wrapped during suture locking.

Results:

The sural nerve was punctured 9 times out of the total of 50 sutures passed for an 18% puncture rate. All 9 punctures occurred in 4 specimens (Image 1), with the remaining 6 cadavers sustaining no punctures. Of the 6 unpunctured cadavers, 5 had all sutures passing anterior to the sural nerve, but in close proximity. One cadaver had all sutures passing posterior to the sural nerve. In all cadavers, removal of the jig and locking of the sutures left the sural nerve free with the sutures well fixed within the Achilles tendon. The sural nerve was also found to be within 1 cm of the lateral edge of the mini-open transverse incision in all cadavers.

Conclusion:

The Arthrex PARS jig was successful in preventing binding of the sural nerve during mini-open Achilles repair, but the sutures are often passed directly through the nerve during the procedure. The sural nerve is also at risk at the lateral edge of the mini-open incision used to insert the jig, and must be carefully protected during dissection down to the tendon.
High Prevalence of Poor Sleep Quality in Chronic Foot and Ankle Conditions
Authors: Kunze Kyle N. , Wu Kevin , Wakefield Connor , Bohl Daniel D. , Holmes George B. , Lin Johnny , Lee Simon , Hamid Kamran S.
Published: October 2019

Category:

Ankle, Hindfoot, Midfoot/Forefoot

Introduction/Purpose:

Sleep disturbance is a known risk factor for poor healing and is associated with medical co-morbidities. Poor sleep quality is also a common complaint of pre-operative patients; yet, there remains a paucity of investigations in this realm. The purpose of this study is to quantify the prevalence of sleep disturbance in patients undergoing surgical management of chronic foot and ankle conditions.

Methods:

Patients scheduled for first-time surgical management of a chronic foot and ankle condition were identified between May and November of 2018 at a tertiary care medical center. Patients with a known sleep disorder or refusal to participate were excluded. Of 139 patients initially identified, 84 (60.4%) were included and administered the Pittsburgh Sleep Quality Index (PSQI) pre-operatively. The PSQI ranges from 0-21, with a score ±5 indicative of poor sleep quality. Patients were also asked to rate their perception of how their foot or ankle pain influenced their sleep quality on a scale of 0-10 (foot ankle pain perception score, FAPPS). A multivariate linear regression model was used to determine predictors of sleep disturbance.

Results:

The mean (+/- standard deviation) age of the 84 included patients was 48.2+/-13.8 years; body mass index (BMI) was 28.9+/-5.0 kg/m2; 52.4% of patients identified as male; and conditions and treatments were varied (Table 1). The mean PSQI score was 7.6+/-4.3 (range, 2-21) and mean FAPPS was 3.2+/-2.7. A total of 64 (76.2%) patients had a PSQI score greater than/equal to 5, indicating presence of sleep disturbance. A total of 68 (81.0%) patients had a FAPPS greater than/equal to 1, indicating that a patient perceived that their foot or ankle pain contributed to sleep disturbance. Age, sex, BMI, and condition/treatment category were not correlated with PSQI score (p>0.05 for each); however, greater FAPPS was an independent predictor of a greater PSQI score (p<0.001).

Conclusion:

Patients presenting for management of chronic foot and ankle conditions have a high prevalence of sleep disturbance pre-operatively. The majority of these patients perceive their foot and ankle conditions to significantly contribute to their sleep disturbance. Further testing assessing post-operative changes to sleep quality is warranted.
Hypertrophic Syndesmotic Impingement and Its Effect on the Ankle Joint
Authors: Kwon Jae Bum , Kim Sungjun , Hong Seung-pyo , Lee Jin Woo , Han Seung Hwan
Published: October 2019

Category:

Ankle, Arthroscopy

Introduction/Purpose:

During ankle arthroscopic surgery, chronic syndesmotic instability is a common combined finding of ankle instability and induces the development of a hypertrophic synovial fold. This pathologic lesion protrudes into the ankle joint cavity in various tissue types, such and hypertrophied synovium, fat or fibrosis. However, the effect of this impingement tissue on the ankle joint and the associated clinical significance have not been well-evaluated. This study aimed to identify the histological type of the syndesmotic impingement tissue and analyze its effect on the lateral talar dome cartilage, in addition to the clinical correlation with the tissue type.

Methods:

A total of 62 patients (64 ankles) with chronic ankle instability and syndesmotic impingement who underwent arthroscopic surgical management from January 2017 to June 2018 were enrolled in this study. During arthroscopic surgery, we visually classified the hypertrophic syndesmotic tissue and performed biopsy. We also evaluated the prevalence of cartilage lesions at the lateral talar dome with its location. The association between the duration of symptoms and tissue diagnosis was also evaluated.

Results:

Based on the pathologic results, 4 samples with fat degeneration, 37 samples with fibrosis, 7 samples with synovial hypertrophy, 12 samples showing mixed type hypertrophy, and 4 samples with other type of hypertrophy were identified. Among the 64 cases, articular cartilage lesions at the lateral talar dome were present in 15 cases. In 10 of 15 cases, the pathologic results revealed the presence of fibrous tissue, while 5 cases of other type including synovial hypertrophy, were identified. In 13 cases, the cartilage lesions were located in the middle third of the lateral talar dome. The patients experienced ankle joint instability for 35.5 ± 33.7 months. Longer duration (>24 months) of instability was associated with a higher rate (81.8%) of fibrotic change in the syndesmosis.

Conclusion:

Repetitive syndesmotic impingement can cause hypertrophic synovial changes; the hypertrophic synovial tissue may evolve into fibrotic impingement tissue as the duration of symptom persistence increases. If the hypertrophic tissues are fibrotic, they may be harder in terms of physical properties and may cause the development of cartilage lesions at the talar dome due to the repetitive load. Considering our results, prophylactic debridement may be effective to prevent the development of cartilage lesions at the talar dome, when hypertrophic tissues are observed during arthroscopic surgeries.
Syndesmotic Implant Removal: Does It Really Improve Ankle Dorsiflexion Range of Motion?
Authors: Kwon John Y. , Wusu Timilien , Briceno Jorge , Kaiser Philip , Cronin Patrick , Leblanc Alyssa , Velasco Brian , Miller Christopher
Published: October 2019

Category:

Ankle

Introduction/Purpose:

There is limited evidence that removal of syndesmotic implants is beneficial. Despite this, many surgeons advocate removal based on previous studies suggesting improved ankle dorsiflexion. Methodologic difficulties make the validity and applicability of previous works questionable. The purpose of this study was to examine the effect of ankle dorsiflexion after syndesmotic implant removal using radiographic measurements of ankle dorsiflexion before and after screw removal utilizing a standardized, applied load.

Methods:

All patients undergoing isolated syndesmotic implant removal were consented for participation. Ankle dorsiflexion was measured radiographically at three different time points: (I) immediately before implant removal intraoperatively, (II) immediately after implant removal intraoperatively and (III) approximately three months after implant removal. A standardized dorsiflexion torque force of 33.4 newton-meter (Nm) was applied to the ankle by a research assistant using a tensiometer at these time points and a perfect lateral radiograph of the ankle was obtained. Four reviewers independently measured ankle dorsiflexion on randomized, deidentified and blinded images using a digital measurement tool. Chi-square tests were used for categorical variables. Paired T-test or analysis of variance (ANOVA) with repeated measures was used for continuous variables. Intra-class correlation coefficients (ICC) were calculated using a 2-way random effects model and the absolute agreement definition.

Results:

29 patients met inclusion criteria and were enrolled in the study. There were 11 men (38%) and 18 women (62%). The mean, and standard deviation, age was 50.3 ± 16.9 years (range 19-80). The mean ankle dorsiflexion pre-operatively, post-op and at 3 month follow up was 13.7°± 6.6°, 13.3°±7.3° and 11.8°±11.3°, respectively (p=0.466). For subsequent analysis, 5 patients were excluded due to potential cofounding effect of retained suture button devices. Analysis of the remaining 24 patients demonstrated similar results with no statistically significant difference in ankle dorsiflexion at all three time points.

Conclusion:

Removal of syndesmotic screws does not improve ankle dorsiflexion motion and should not be used as an indication for screw removal.
Outcomes Following Calcaneal Autograft with a Reaming Graft Harvester
Authors: Langan Travis M. , Consul Devon , Law Rona , Hyer Christopher F.
Published: October 2019

Category:

Hindfoot

Introduction/Purpose:

Autogenous bone graft remains the standard bone graft in foot and ankle surgery when filling a bone void or adding biology to an arthrodesis site. Harvesting autograft can have serious donor site morbidity with an average complication rate of 8% and reports as high as 25%. Complications range from persistent pain to severe infection. Most procedures in the foot and ankle require only a small volume of graft. Using a small reaming graft harvester, surgeons can harvest autograft from the ipsilateral calcaneus. This is done within the same surgical field and requires minimal additional operative time. The purpose of this article is to review a population of patients who underwent calcaneal autograft harvesting with a reaming graft harvester and evaluate the outcomes of the procedure.

Methods:

From August 2015 to February 2018, all patients who underwent calcaneal autograft harvesting by a single surgeon were identified and reviewed. Patients were included if they had autograft harvested from the calcaneus on the ipsilateral operative limb using a reamer bone graft harvester and if they had complete clinical follow up of at least 6 months. Patients were excluded if they had autograft from a site other than the ipsilateral calcaneus, had a previous harvest from the ipsilateral calcaneus, or if they did not have full follow up of at least 6 months. Outcomes of interest were major and minor complications, intra- operative complications, and long term radiographic findings. Patients required graft for numerous primary procedures including a variety of arthrodesis or filling of bone voids. Postoperative protocols and return to weightbearing times varied with the accepted protocols for the primary procedure.

Results:

300 patients were identified and met inclusion criteria. Average follow up was 12.6 months. There was 1 major complication (0.3%) consisting of a calcaneal stress fracture that healed with a period of 4 weeks of non weightbearing followed by 4 weeks of protected weightbearing. There were 3 minor complications (1%) consisting of transient painful scar and medial heel pain that all resolved uneventfully. There were no intraoperative complications while performing the 300 procedures. There were no incidences of neurovascular damage. Of the patients with over 1 year radiographic follow up, all harvest sites were still visible on lateral plain film radiographs.

Conclusion:

Using a small reamer to harvest calcaneal autograft for foot and ankle surgeries that require a small to moderate amount of bone graft is safe and effective. Approximately 4 cc of graft can be harvested very quickly without needing to prepare another surgical site for harvesting. The complication rate for harvesting calcaneal autograft was found to be extremely low in this study, despite the harvest site remaining visible on radiographs past 1 year. The proposed technique can be extremely useful to the foot and ankle surgeon.
The Clinical, Radiologic Outcomes of Indirect Anteroposterior Screw Fixation for Posterior Malleolar Fracture in Rotational Ankle Fractures: Comparison with Syndesmosis Fixation
Authors: Lee Sunghyun , Kwon Hoiyoung
Published: October 2019

Category:

Ankle

Introduction/Purpose:

The posterior malleolus is an important soft tissue attachment for the posterior inferior syndesmosis ligament. Recent studies suggested that direct fixation of a sizable posterior malleolar (PM) fracture through posterolateral approach would act to stabilize the syndesmosis and minimize or eliminate the need for trans-syndesmotic fixation. Indirect anteroposterior (AP) screw fixation was an alternative method, which represent relatively low complication. However, there were few studies to evaluate the stability of syndesmosis after indirect anteroposterior screw. The purpose of this study was to define the rate of syndesmotic instability after anteroposterior screw fixation and to compare to the clinical and anatomical outcomes with indirect reduction without fixation.

Methods:

We performed a retrospective review between 2009 and 2015 of consecutive patients who underwent surgery with sustained rotational ankle fractures including PM fractures. The exclusion criteria included age <18 years, diabetic neuropathy, tibial pilon fractures, previous ankle fracture repair and not available at minimum 1 year follow up. After the fibula and medial malleolar fracture fixation, the PM was fixed with an AP screw, leaving some of relatively smaller and indirect reduced PM fractures unfixed. Patients were sorted into 2 groups according to the presence (group F) or absence (group N) of AP screw fixation of PM. Then, both groups were divided according to the intraoperative necessity of syndesmotic fixation. The demographics, PM fragment size and syndesmosis widening comparing intact ankle on CT at 1 year postoperatively were recorded for each fracture. 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. Syndesmotic fixation was required in 17 of 78 (21.8%) and 24 of 88 (72.7%) in group F and N, respectively (p=0.012). Postoperative and follow-up FAOS scores were similar in the four subgroups. The tibiofibular distance on CT was greater in the patients without syndesmotic screw fixation in group F and N (p=0.036 and 0.021, respectively).

Conclusion:

Indirect AP screw fixation of the PM fracture in rotational ankle fractures might be support syndesmotic stability and, thus, lower the rate of syndesmotic fixation. Also, these patients have functional outcomes at least equivalent to outcomes for patients having syndesmotic screw fixation. However, in AP screw fixation group, syndesmosis widening was evaluated without syndesmosis fixation, which could be resulted in degenerative arthritis change. Therefore, our data demonstrate that indirect AP screw fixation of PM fracture alone could not restore syndesmotic stability perfectly.
Treatment of Insertional Achilles Tendinopathy with MRI Confirmed Small or No Tear Using a Gastrocnemius Recession
Authors: Long Joseph M , Whitehead Brent , Zehnder David , Large Bryan , Cheney Nicholas , Law Timothy
Published: October 2019

Category:

Ankle

Introduction/Purpose:

Insertional Achilles tendinopathy can be a distressing problem for an active patient. Treatment begins conservatively, and when this fails a patient’s next best option may involve operating on the affected tendon. Depending on the disease state of the tendon, the surgeon may decide to repair or augment the Achilles with a flexor hallucis longus (FHL) transfer. The current literature supports the gastrocnemius recession for non-insertional cases, but is inconsistent in its efficacy for insertional cases. Our study looks at how patients with insertional Achilles tendinopathy with a small tear involving 20% of the tendon or less responded to an isolated gastrocnemius recession. Our hypothesis was that patients could do well without the need for a large repair or FHL transfer procedure.

Methods:

We retrospectively reviewed patients who underwent an isolated gastrocnemius recession for recalcitrant insertional Achilles tendinopathy between January 2015 and July 2018. Patients were included based on the diagnosis of insertional Achilles tendinopathy, having an MRI confirming tendinopathy, a tear involving less than 20% of the tendon or no tear, and no other concurrent pathologies. These criteria yielded 14 patients. One of these 14 patients was removed from the data analysis due to non-surgical complaints after surgery stemming from new onset posterior ankle pain. The patient charts were reviewed for their subjective VAS pain scores during office visits pre and postoperatively. Immediate preoperative visit, initial postoperative visit and final visit VAS scores were recorded.

Results:

The average time of chart follow up for the 13 patients included in the study was 15.5±10.5 weeks postoperatively (range 4-38). 2 patients were found to have a tear <20% (15%), and the remaining 11 patients were found to have no tear on their MRI (85%). The average final preoperative VAS pain score for the patients was 5.4±1.8 (range 3-9). The average final postoperative VAS pain score for the patients was 0.9±1.3 (range 0-5). These values were found to be statistically different (p<0.001). Of note all patients saw a reduction in their pain score of at least 2 points.

Conclusion:

Previous literature is inconclusive on the efficacy of the gastrocnemius recession for insertional Achilles tendinopathy. No other study has identified the amount or type of tendon involvement by advanced imaging. Our study supports the notion that patients with MRI confirmed tendinopathy and a tear involving less than 20% of the tendon or no tear, often do quite well in reaching a reduction in their pain. Our study is limited in power due to our small sample size, but the results suggest that this procedure deserves more attention for the treatment of insertional Achilles tendinopathy when appropriate.
Subtalar Nonunion Following Tibiotalocalcaneal Fusion Using an Intramedullary Nail: A Case Series of Errant Entry Points
Authors: Martella Anthony , Yue Ruixian , Boin Michael , Rogozinski Jonathan , Flanigan Trenden , Purcell Kevin , Laughlin Richard
Published: October 2019

Category:

Hindfoot

Introduction/Purpose:

Tibiotalocalcaneal (TTC) arthrodesis is a procedure used to treat hindfoot deformity and/or arthritis. Retrograde intramedullary nails have been used as a method of fixation. The nails are either straight or have a bend to accommodate valgus alignment of the hindfoot. Studies comparing nail types or analysis of nonunions are lacking in the available literature on the subject despite a reported nonunion rate of up to 20%. The purpose of this study was to report a series of subtalar nonunions that all had an entry point that was too medial on the calcaneus resulting in inadequate purchase of the nail in the calcaneus.

Methods:

Six cases of subtalar nonunion were retrospectively reviewed. All were referred for second opinion. Evaluation consisted of examination, radiographs and CT scans. Patient demographics, comorbidities and findings common to all cases were recorded.

Results:

Presenting complaints in all cases were persistent swelling. Non-neuropathic cases all had hindfoot pain. In this series, all the implants were straight nails. Radiographs and CT scans revealed that all cases were done for severe valgus deformity with subtalar subluxation. In each of the cases, the deformity was under corrected and the nail entry point was too medial on the calcaneus which resulted in reaming out the medial wall of the calcaneus, decreasing the amount of fixation obtained with the nail. In each of the cases, the medial wall of the calcaneus was deficient and the nail had no medial containment.

Conclusion:

Severe valgus deformity with subtalar subluxation is a risk factor for subtalar nonunion when the deformity is under corrected and a straight nail is used. Ensuring that the tibia talus and calcaneus are collinear and that the entry point in the calcaneus is sufficiently lateral are important factors to consider when addressing this type of deformity. Accurate intraoperative imaging is essential to ensure proper positioning of the entry point to avoid reaming out the medial wall of the calcaneus and to ensure adequate purchase of the nail in the calcaneus.
Does Insurance Status Affect Access to Care Among Ankle Fracture Patients? An Institutional Retrospective Study
Authors: McKissack Haley , He Jun Kit , Moraes Leonardo V. M. , Anderson Matthew , Wislon John T. , Viner Gean C. , Jha Aaradhana J. , Mcmurtrie James T. , Shah Ashish B. , Naranje Sameer M.
Published: October 2019

Category:

Ankle, Trauma

Introduction/Purpose:

Ankle fractures are urgent, and often emergent injuries which require immediate evaluation and treatment. Delayed access to care may subject the patient to increased risk of complications, particularly if surgical management is warranted. Medicaid is a state and federal insurance program in place for those with low income, which has previously been associated with delayed access to care among patients with ACL tears and total hip arthroplasties. Studies have also shown delayed access to care among ankle fracture patients; however these studies have used hypothetical patients rather than existing data regarding timeliness of care. The purpose of this study is to assess whether patient insurance status affects access to care using data from a single institution.

Methods:

Patients who underwent open reduction and internal fixation for an ankle fracture between the years 2008 and 2018 at a single institution were identified by CPT codes 27829, 27784, 27822, 27814, 27769, 27792, and 27766. Patients who had polytraumatic injuries, open injuries, Medicare, no insurance, indigent/charity insurance, self-pay, or whose insurance information was not available were excluded. Insurance status was retrospectively identified as well as date of injury, date of first visit to the institution’s hospital for the injury, and date of surgery. Time elapsed from date of injury to date of surgery, date of injury to date of first visit, and date of first visit to date of surgery was compared between patients with private insurance and Medicare. P-values of less than 0.05 were considered statistically significant.

Results:

Results showed statistically significant differences in mean time from injury to first appointment and mean time from injury to surgery between patients enrolled in Medicaid and those with private insurance. Average time from injury to first appointment was 3.1 days and 6.6 days for privately-insured patients and Medicaid patients, respectively (p<0.0001). Average time from injury to surgery was 8.1 days for patients with private insurance, and 12.7 days for patients enrolled in Medicaid (p<0.0001).

Conclusion:

Patients who are enrolled in Medicaid have significantly delayed access to care as compared to those who have private insurance. For ankle fracture patients this is a critical healing time, and delayed care may result in increased costs, increased utilization of healthcare resources, higher complication rates, and poorer patient outcomes. Therefore, it is important that the orthopaedic community continues to progress toward improvising and expanding access to care for all patients.
Biomechanical Evaluation of an Augmented Medial Capsular Repair for Hallux Valgus Surgery
Authors: Miller Christopher P. , Paulus Megan , Kreulen Christopher , Harris Thomas , Giza Eric
Published: October 2019

Category:

Bunion

Introduction/Purpose:

Hallux valgus correction is often complicated by recurrence in the setting of inadequate soft tissue balancing. The etiology of recurrence is multifactorial, but a key factor is the quality of the medial capsulorrhaphy which is limited by the quality and strength of the soft tissues. These soft tissues are often attenuated with loss of integrity due to the longstanding bunion deformity. We hypothesize that the medial capsulorrhaphy augmented with a suture tape construct will create a stronger repair.

Methods:

8 unmatched and 16 matched cadaveric foot specimens were prepared. None had bunion deformities. The 8 unmatched samples were tested to determine the strength of the native medial capsule. The 16 matched samples underwent a longitudinal medial capsulotomy, eminence resection and medial capsulorrhaphy with or without augmentation with a suture tape construct. The samples were then tested in a biomechanics lab to determine the strength of the medial capsulorrhaphy.

Results:

The mean maximum moment for the intact, capsular repair and suture tape groups were 2.19 ± 0.639 Nm, 0.225 ± 0.074 Nm and 0.968 ± 0.581, respectively, P<0.001. The mean stiffness for the intact, capsular repair and suture tape groups were 8.06 ± 3.75 N/mm, 1.463 ± 0.553 N/mm, and 4.438 ± 4.035 N/mm, respectively, P=0.003. The suture tape provided 4.3x higher maximum moment and 3x higher stiffness compared to traditional medial capsulorrhaphy.

Conclusion:

The study demonstrates that a medial capsular repair augmented in a cadaveric model of medial capsulorrhaphy to provide greater strength compared to conventional suture repair. Recurrence of hallux valgus after surgery is multifactorial. One element is the strength of the medial imbrication and capsular repair at the 1st metatarsal phalangeal joint (MTPJ). The study presents biomechanical data demonstrating that this repair is strengthened with suture tape augmentation at the medial 1st MTPJ. This may result in decreased recurrence and potentially improved patient satisfaction following bunion correction.