bluuebunny/crossref_metadata_2025 huggingface dataset:
The Effect of a Leveling Procedure for Addressing Bony Step-off Following Medial Displacement Calcaneal Osteotomy
Authors: Kim Jaeyoung , Kim Chulho , Day Jonathan
Published: November 2020

Category:

Hindfoot; Other

Introduction/Purpose:

Due to the nature of the medial displacement calcaneal osteotomy (MDCO), bony step-off at the osteotomy site is inevitable and can lead to lateral prominence pain. Theoretically, this bony prominence can lead to irritation of the peroneal tendon, sural nerve, and overlying skin resulting in pain and discomfort. While these symptoms have been loosely described in the literature, the incidence and prevention are largely unexplored. The purpose of this study is to investigate the incidence of lateral prominence pain after MDCO as well as the efficacy of a leveling procedure (LP) as a preventive technique.

Methods:

We retrospectively identified 175 feet in 160 patients who underwent MDCO from 2016 to 2018. Of the 175 feet, 102 underwent MDCO with LP, and 73 without LP. LP was performed after calcaneal fixation by flattening the residual bony prominence using rongeur and bone impactor (Figure 1). Lateral prominence symptoms were defined as pain present at 12 month follow-up after MDCO, either 1) over the lateral prominence on direct contact with the floor or footwear, or 2) associated with callus formation over the osteotomy site due to continued irritation. The overall incidence of lateral prominence symptoms after MDCO and the incidence with or without LP were investigated. The relationship between the amount of calcaneal displacement and the occurrence of lateral prominence pain with or without LP was also analyzed.

Results:

The overall incidence of lateral prominence was 12.6% (22 of 175): 4.9% (5 of 102) in patients who underwent LP and 23.3% (17 of 73) in patients who did not undergo LP (p<0.001, Figure 2). In patients who did not undergo LP, a significant correlation was observed between incidence of lateral prominence symptoms and the amount of calcaneal displacement (p=0.013). This correlation was not observed in patients who underwent MDCO with LP (p=0.617). Six patients (one who had LP, five who did not have LP) underwent ostectomy as a secondary procedure to relieve symptoms at average 11.2 months (range, 8- 14) after the index surgery.

Conclusion:

It is important to address the bony step-off following MDCO procedure, as failure to do so may result in lateral prominence pain postoperatively. We demonstrate that a leveling procedure to remove the step-off yields promising results. Therefore, we suggest concomitant LP especially when a larger amount of correction is needed in performing MDCO.
Short-Term Complications Following Early Protected Weight Bearing after Flatfoot Reconstruction when Utilizing a Fibertape Device for Spring Ligament Reefing Augmentation
Authors: Kim Morgan S. , Vannatta Emily , Stauch Chris M. , Juliano Paul J. , Aynardi Michael C. , Koroneos Zachary , Luick Laura R.
Published: November 2020

Category:

Ankle

Introduction/Purpose:

In an estimated 70% of cases of Adult Acquired Flatfoot Deformity (AAFD) reconstruction, the spring ligament is elongated and/or damaged. Spring ligament reefing can be performed through several techniques including augmentation with Fibertape devices. In addition, biomechanical studies have demonstrated its safety and suggest early weight bearing may be performed. The purpose of this study is to evaluate the outcomes of early weight bearing following flatfoot reconstruction with use of InternalBrace augmentation for spring ligament reefing when performed in combination with medical displacing calcaneal osteotomy (MCO) and FDL tendon transfer.

Methods:

From 2016-2018, 45 patients underwent flatfoot reconstruction (MCO, FDL transfer, and gastrocnemius recession) with spring ligament reefing and augmentation with the InternalBrace device. All surgeries were performed by the senior orthopaedic surgeons (PJJ & MCA). Institutional early post-operative weight bearing protocol involves weight bearing as tolerated in a splint with crutches for two weeks, transitioning at 2 weeks to a Cam boot with 1 wedge WBAT. At 4 weeks, the patient is weaned off crutches and recommended to start therapy restricting excessive eversion and concentrating on calf strengthening, gait, and ROM. At weeks 6-8 they are weaned from the Cam boot into lace up ASO and shoe with arch support. Data were recorded at 2 weeks, 6 weeks, 12 weeks, 6 months and at yearly intervals. Outcomes and complications were documented.

Results:

Of the 45 cases there were no complications related to early weight bearing. Radiographic bony union rate of the MCO was 100% (45/45). Moreover, there was no loss of fixation of either the FDL transfer or spring ligament reefing with InternalBrace augmentation with early weight bearing. Lastly, radiographic evaluation noted no loss of Meary’s talo-first metatarsal angle when comparing initial postoperative radiographic to their final follow up. Additional complications in our cohort included the following: removal of painful hardware (1, 2.22%), sural neuritis (2, 4.44%), superficial cellulitis (1, 4.44%), and delayed lateral wound healing (1, 2.22%).

Conclusion:

Preliminary data shows that early protected weight bearing after flatfoot reconstruction and augmentation of the spring ligament with the InternalBrace device is safe and demonstrates few complications and no early loss of correction.
The Epidemiology and Trends of Primary Total Ankle Arthroplasty and Revision Procedure in South Korea Between 2007 and 2017
Authors: Kim Sung-Jae
Published: November 2020

Category:

Ankle Arthritis

Introduction/Purpose:

The aim of this study was to investigate the surgical trends of primary total ankle arthroplasty (TAA) and revision procedure in South Korea from 2007 to 2017 using the national population-based data.

Methods:

We reviewed the national health insurance data of South Korea from 2007 to 2017. The data includes diagnosis codes, procedure codes, prescriptions, medical costs, and other demographic data. Trends of primary diagnosis for primary TAA were evaluated. Annual trends and incidences per 100,000 person-years of primary TAA and revision procedures as well as compound annual growth rate (CAGR) during the study period were analysed. Surgical trends according to patients’ age, hospital grades, and insurance systems were also evaluated.

Results:

Primary diagnosis for primary TAA was mostly degenerative arthritis (6501 cases, 90.5%). From 2007 to 2017, the total number of cases of primary TAA and revision procedures was 7183 and 585, respectively. The number of cases in 2007 of primary TAA were 313; there were no cases of revision. The number of cases in 2017 of primary TAA were 986 and of revision were 108. The CAGR during this period was 28.6% for primary TAA and 44.6% for revision procedures. Incidences per 100,000 person- years in 2017 were 1.91 for primary TAA and 0.21 for revision procedures. The average cost paid by patients themselves was 813$ (19%) and by the national health insurance service was 3480$ (81%).

Conclusion:

Trends of primary TAA and revision procedures have been steadily rising in South Korea during the 11-year study period.
Measurement of Physical Activity Level in Patients with Ankle Osteoarthritis
Authors: Kimura Seiji , Yamaguchi Satoshi , Ono Yoshimasa
Published: November 2020

Category:

Ankle Arthritis

Introduction/Purpose:

Maintaining physical activity (PA) is important for reducing the risk of lifestyle-related diseases and fundamental to keep healthy. PA is reduced in patients with knee and hip osteoarthritis, but PA of patients with ankle osteoarthritis has not been clarified. The purpose of this research is to compare PA level and proportion of patients who meet recommendations for health between ankle osteoarthritis and control patients.

Methods:

The subjects were 50 patients with ankle osteoarthritis (OA group), and 50 patients with minor hand disease matched by age and gender (control Group), who visited our outpatient clinic from October 2016 to April 2019. Both groups had 16 men and 34 women, with an average age of 68 years for the OA group and 66 years for the control group. The visual analogue scale for foot pain was 5.5 on average in the OA group and 0.3 in the control group. The physical activity for one week was measured using a tri-axial accelerometer. Unpaired t-tests were used to compare the number of steps per day and moderate or higher activity time between the OA group and the control group. The proportions of the OA group and the control group that met the recommendations set by Japan and the World Health Organization were compared using Fisher’s exact test.

Results:

The number of steps per day was 4177 +- 2312 steps in the OA group and 6802 +- 2851 steps in the control group, which was significantly lower in the OA group (p <0.001). Moderate PA time was 448 +- 232 minutes in the OA group and 634 +- 336 minutes in the control group, OA group was significantly lower (p = 0.02). Vigorous PA time was no difference between the two groups. The WHO recommendations were met by 45 patients in the OA group and 48 in the control group, no difference. The Japanese criterion were met by 33 patients in the OA group and 46 in the control group, which was significantly lower in the OA group (p = 0.001).

Conclusion:

PA of patients with ankle osteoarthritis was less than control patients. The proportion of patients meeting recommendations for health was lower in the OA group than the control group.
Novel Pathology Classification System (FEMASK-Score) for Charcot Neuropathic Arthropathy Reveals Intraneural Vasculopathy and Predicts Outcome
Authors: King Jesse , Murie Ben , Fanburg-Smith Julie C. , Stauch Chris M. , Flemming Donald , Klein Michael J. , Frauenhoffer Elizabeth E. , Fritsche Madelaine W. , Smith Jessica , Elfar John , Aynardi Michael C.
Published: November 2020

Category:

Basic Sciences/Biologics; Ankle; Diabetes; Midfoot/Forefoot

Introduction/Purpose:

Charcot neuropathic arthropathy (CNA) is a debilitating, rapidly destructive degenerative joint disease that occurs in diabetic, neuropathic midfoot. Clinicoradiologic assessment for CNA previously relied on Eichenholtz Stage. There is limited data on CNA histopathology. The goal of this study was to independently develop a histopathologic scoring system for Charcot neuropathic arthropathy.

Methods:

Retrieval of surgical pathology specimens from neuroarthropathic CNA patients (2012-2019) were analyzed to evaluate joint soft tissue and bone. Considering progression from large to small periarticular bone fragments to resolution, we devised and applied a CNA FEMASK-score (named after coauthors): 0= intraneural arteriolosclerosis; 1= large bone fragments without host histiocytic response; 2= mixed bone fragments with host histiocytic response; 3= small minute bone spicules resorption to fibrosis. Clinical modified Eichenholtz staging and outcome were then compared the CNA FEMASK-score to assess for associations between these three elements.

Results:

Forty-eight cases of CNA included 34 males and 14 females, mean age 60.3 and age range 28-83 years, with clinical diabetes mellitus (predominantly Type II) and longstanding neuropathy. Elevated HbA1C, Eichenholtz stage, American Society of Anesthesia score, and Charlson comorbidity index were predictive of amputation. Pathologic specimens varied from fixation tissue to amputation. In addition to neurotraumatic, neurovascular and inflammatory findings, a distinctive intraneural hyalinized arteriolosclerosis was observed. FEMASK-scores:1 = 10%, 2= 58%, and 3=32%. FEMASK-score comparisons were 98% accurate compared with the modified Eichenholtz criteria scores of each patient and 98% reproducible among pathologists. FEMASK 2 and 3 correlates strongly with amputation.

Conclusion:

Our novel CNA FEMASK-score classification, derived from the largest cohort of diabetic neuropathic specimens, is reproducible, explains pathophysiology, correlates with Eichenholtz, and predicts amputation. The unique intraneural vasculopathy observed contributes to CNA etiology.
The Positive Association Between Metatarsal Length and Meary’s Angle and Hammertoe Deformity
Authors: King Jesse , Stauch Chris M. , Ridenour Ryan M. , Aydogan Umur
Published: November 2020

Category:

Lesser Toes; Midfoot/Forefoot

Introduction/Purpose:

Hammertoe deformities are the most common pathology of the forefoot, accounting for up to 48% of all forefoot operations. There is currently limited evidence documenting differences in foot radiographs and radiographic measurements that may represent a predisposition to developing hammertoe deformity. The purpose of this study was to investigate whether patients with hammertoe deformity demonstrate increased radiographic measurements of first, second, or third metatarsal (MT) lengths as well as Meary’s angle compared to a healthy control group.

Methods:

Following IRB approval, an institutional radiology database was queried from January 2009-2018 for patients with ICD- 9 and ICD-10 diagnosis codes for hammertoe deformity of the 2nd or 3rd phalange. Control cases were selected using diagnosis codes for acute plantar fascial pain in the same timeframe with medical record review to exclude patients with prior lower extremity injury, surgery or pathology. 234 hammertoe and 110 control patients met inclusion and exclusion criteria. Automated 1:1 case-control matching was performed to control for age, sex and laterality. Following matching, the sample size consisted of 80 patients in each cohort. Proximal to distal end-to-end articular surface radiographic lengths were documented for metatarsals and phalanges of the 1st, 2nd and 3rd rays on anteroposterior radiographs. Lateral talar-first metatarsal (Meary’s) angle was measured using weightbearing sagittal radiographs by calculating the angle formed by lines that bisect the talar neck and anatomic neck of the first metatarsal.

Results:

A total of 160 patients (80 cases and 80 controls) were included in the study. Mean age was 47.7 years among hammertoe cases and 47.5 years among controls (p=0.92). 54 of 80 cases in each group were female. There was a statistically significant increase in the average Meary’s angle among hammertoe patients (5.23 +- 8.60°) compared to controls (2.15 +- 5.96°) (p<0.01). The average length for the 1st, 2nd and 3rd metatarsals were 65.6, 80.0, and 76.7 mm, respectively for the hammertoe patients and 62.8 mm, 76.0 mm, and 73.5 mm among control cases, respectively. For all three metatarsals, this difference was statistically significant (p<0.01; Table 1). There was no statistically significant difference between lengths of the proximal or distal phalanges.

Conclusion:

Patients with hammertoe deformity were associated with an increased length on the 1st, 2nd and 3rd metatarsals. Also, these patients demonstrated an increased Meary’s angle creating pes planus deformity. These results illustrate the importance of both medial column instability and long metatarsal length in the development of hammertoe deformity. [Table: see text]
Long-Term Patient Reported Outcomes after Correction of Traumatic Foot Drop
Authors: Kohring Jessica M. , Karnyski Steven , Joo Peter , Liu Andrew Y. , Baumhauer Judith F. , Flemister Adolph S. , Ketz John P.
Published: November 2020

Category:

Trauma; Ankle

Introduction/Purpose:

There is limited literature on patient reported outcomes after tendon transfer for traumatic foot drop. The purpose of this study was to determine long-term patient reported functional outcomes after posterior tibialis tendon (PTT) transfer in patients with foot drop resulting from a traumatic common peroneal nerve injury.

Methods:

Between August 2006 to January 2019, 31 patients underwent PTT transfer for foot drop secondary to a traumatic injury to their common peroneal nerve at our institution. The average follow-up was 14 months. A retrospective chart review was performed to document physical exam measures and to review postoperative radiographs for changes in foot alignment. There were 17 out of the initial 31 patients available at a mean follow-up of 5.9 years who responded to a phone questionnaire, including the Foot and Ankle Ability Measure (FAAM) questionnaire, and questions on brace and assistive device use, activity level, and satisfaction with surgery.

Results:

Preoperatively, all patients had an equinus contracture with no dorsiflexion strength, abnormal gait, and used an ankle- foot orthosis (AFO) or pneumatic boot for ambulation. Postoperatively, the average ankle dorsiflexion strength was 4/5 with 28/31 patients reporting a normal gait and 26/31 not using a brace for ambulation. Postoperative radiographs did not show changes in alignment or progression to flatfoot deformity. For the subset of 17 patients who responded to the phone questionnaire, the mean FAAM ADL subscale score was 68.1 and the Sport subscale score was 52.1 at an average of 5.9 years after surgery. The majority of patients (76%) were very or quite satisfied with the outcome of surgery and 15/17 (88%) patients reported they would undergo the PTT transfer procedure again.

Conclusion:

Posterior tibialis tendon transfer for patients with foot drop secondary to a traumatic injury to their common peroneal nerve showed a high satisfaction rate and improvement in function after surgery without the need for brace or assistive device use at long-term follow-up at an average of 6 years. Additionally, there was no progression to flatfoot deformity after posterior tibialis tendon transfer at 1 year postoperatively. [Table: see text]
Results of Staged Treatment with External Fixation for High Energy Calcaneus Fractures
Authors: Kohring Jessica M. , Neumaier Mackenzie A. , Ketz John P.
Published: November 2020

Category:

Trauma; Hindfoot

Introduction/Purpose:

High energy calcaneus fractures have significant soft tissue compromise and typically poor outcomes. The purpose of this study was to describe patient complications and outcomes, after undergoing staged treatment for high energy calcaneus fractures, including initial treatment with medial calcaneal external fixation followed by definitive reconstruction.

Methods:

A retrospective chart review with prospective data was performed from April 2013 to February 2019. Inclusion criteria for the study included: patients >18 years of age, closed Sanders III and IV fractures or open fractures of the calcaneus. Patients were initially treated with placement of a medial based external fixator with closed reduction. Once the soft tissue envelope had improved, definitive fixation was performed, either ORIF or ORIF with primary subtalar fusion.

Results:

There were a total of 15 patients that met inclusion criteria for the study. 9 of the fractures were open and 6 were closed. The medial calcaneal external fixation (ex-fix) was placed at a mean of 2.0 (0-12) days after initial injury. The definitive procedure occurred at a mean of 23.6 (12-42) days after ex-fix placement. 11 of the patients underwent calcaneus fracture ORIF with primary subtalar (ST) fusion and 4 patients were treated with calcaneus fracture ORIF alone. 14 (93%) of the patients showed radiographic union at an average of 6.7 months. Mean PROMIS scores showed improvement in physical function, mood, and a decrease in pain at an average of 19 (5-72) months after initial injury. The average VAS pain score was 3.5 (0-7).

Conclusion:

A staged protocol for high-energy and open calcaneal fractures is an effective tool in treating these difficult injuries. It allows the soft tissues to improve while maintaining length and alignment of the fracture for definitive fixation and minimizing complications. There were improvements in physical function, mood, and a decrease in pain at final follow-up of almost 2 years. [Table: see text]
Ankle Joint Pressure in Supination-External Rotation Injuries: A Dynamic Biomechanic Cadaveric Study
Authors: Krause Fabian , Zderic Ivan , Seidel Angela , Gueorguiev Boyko , Attinger Marc C. , Foesel Andreas
Published: November 2020

Category:

Ankle; Basic Sciences/Biologics; Trauma

Introduction/Purpose:

In isolated lateral malleolar fractures of the supination-external rotation (SER) type and competent medial stabilizers (type II and III), non-operative treatment has yielded excellent outcome. With complete rupture of the deltoid ligament (SER type IV) fracture instability increases substantially. The rationale for operative treatment of SER type IV fractures is based upon good clinical results and previous biomechanical studies. A significant reduction of the ankle contact area that however is caused by an artificially forced lateralization of the talus in the ankle mortise has been demonstrated. Presumed resultant elevated joint contact stresses are thought to lead to ankle arthritis in the longterm.

Methods:

In 12 lower leg specimen SER type injuries were simulated by gradual bony and ligamentous destabilization of the ankle from lateral to medial according to the mechanism of injury as described by Lauge and Hansen. High-resolution pressure sensors placed in the ankle joint recorded tibio-talar pressure changes at physiologic weightbearing (700N) in three positions (plantigrade, 10° dorsiflexion and 20° plantarflexion).

Results:

With increasing instability changes of the ankle kinematics were seen in SER II and III fractures with the same trend also in SER IV lesions. In the plantigrade position, the medial clear space (MCS) increased significantly from an average of 2.5+-0.4mm (no fracture) to 3.9+-1.1mm (SER type IV fracture). However, the corresponding peak pressure increased only slightly from 2.6+- 0.5 mPa to 3.0+-1.4 mPa on average, and the contact area decreased slightly from 810+-42 mm2 to 735+-27mm2 on average representing a non-significant reduction of only 9% of the contact area (p=0.08) after the deep deltoid ligament was completely dissected.The comparison of the results in plantigrade and plantarflexed position revealed substantial differences for MCS, contact area and center of force.

Conclusion:

Under physiologic load SER type IV isolated lateral malleolar fracture with completely disrupted deep deltoid ligament led to a significant increase of the MCS, but neither to a significant decrease of the of the joint contact area nor significant increase of peak pressure. Clinical Relevance: The findings of this biomechanical study support the recently reported good clinical results of non-operative treatment of SER type II to IV fractures.
Compression Wrapping for Calcaneal Fractures after Extensile Lateral Approach: Results of a Retrospective Study
Authors: Kulwin Robert , Shah Sapan , Haddad Steven L. , Weatherford Brian M.
Published: November 2020

Category:

Trauma

Introduction/Purpose:

Displaced intraarticular calcaneus fractures comprise the majority of all calcaneus fractures. Many are indicated for open reduction and internal fixation (ORIF) through an extensile lateral approach (ELA). Unfortunately, this approach has reported complication rates of up to 32%. Improved edema management may reduce the incidence of complications. While compression wrapping has been shown to reduce wound complications in ankle arthroplasty, it has not been well studied in lower extremity trauma. This study aimed to evaluate the benefit of compression wrapping in calcaneus fractures treated surgically with an ELA.

Methods:

This study included 19 patients from 2015-2018 who underwent ORIF of closed intra-articular calcaneal fractures via an ELA by two surgeons. Demographics, comorbidities, fracture characteristics, and time to surgery were recorded. Following surgery, the extremity was initially immobilized in a short leg splint with transition to serial compression wrappings on postoperative day two. Wrappings involved application of multi-layered cotton cast padding and short stretch elastic bandages to the extremity in a distal to proximal fashion. Wraps were replaced every three days by trained physiotherapists until the two- week postoperative visit. The primary outcome was development of a wound complication. A minor complication was defined as wound appearance prompting initiation of oral or IV antibiotics or local wound care. A major complication was defined as development of flap necrosis or return to the OR for debridement.

Results:

Mean age was 47.7 years. 3 patients (15.7%) were diabetic, and 7 patients (36.8%) were smokers. Mean BMI was 26.9 kg/m2 (SD 4.4). Mean time to surgery was 11.4 days from injury (SD 6.93). The rate of minor soft tissue complication was 4/19 (26.3%); 2 patients required oral antibiotics only, 1 local wound care only, and 1 both antibiotics and local wound care. The rate of major complication was 2/19 (10.5%), with 1 patient requiring a return to OR and another requiring both a return to the OR and IV antibiotics. Of those patients, 1 was noncompliant with the protocol. All patients progressed to eventual soft tissue healing. Statistical analysis identified diabetes as a risk factor for any complication (p=0.02, relative risk 5.3).

Conclusion:

Compression wrapping resulted in a low incidence of major soft tissue complications in calcaneus fractures treated with an extensile lateral approach. Compression wrapping is an effective method of post-operative soft tissue management for calcaneal fractures, and may have further applications for similar high energy foot and ankle fractures. Further studies are warranted to determine whether this novel wound care technique is superior to standard post-operative wound care.
Restoration of Talar Height, Alignment, and Implant Survival after Revision Total Ankle Arthroplasty with Minimum 2-Year Follow-up
Authors: Kulwin Robert , Haddad Steven L.
Published: November 2020

Category:

Ankle Arthritis; Ankle; Other

Introduction/Purpose:

With the introduction of improved implants and long-term outcome data, total ankle arthroplasty (TAA) is becoming an increasingly common surgical treatment for end-stage ankle osteoarthritis. However, the treatment of a failed primary TAA remains a significant challenge. Ankle arthrodesis as a salvage procedure results in high rates of non-union and collapse. Revision arthroplasty is an alternative to arthrodesis, but there is little published data on the outcomes of revision total ankle arthroplasty (RTAA). This study presents 2-year outcomes after RTAA using a modular prosthesis and metal/cement augmentation to reconstitute talar height, as well as restore sagittal and coronal alignment.

Methods:

A retrospective review was performed on 23 patients who underwent RTAA after failed primary TAA. Demographic data, talar height, coronal and sagittal alignment, and range of motion pre-revision and at most recent follow up were recorded. Failure was defined as need for revision surgery during the follow up period. Radiographic measurements were performed on weight bearing lateral and AP radiographs. For Agility implants, measurement on weight-bearing computed tomography (WBCT) was required. The measurement methodology was performed on both radiographs and WBCT for validation and measurements were consistent across all implants.

Results:

Patient follow-up ranged from 2 to 3.9 years, with a mean of 2.56 years. 17 of 22 RTAA did not require further revision. Of the five failures, one was due to deep infection, four to subsidence of the talar component. For the 17 successful revisions, average pre-operative coronal malalignment was 3.8◦ (range 7.4◦ varus to 15◦ valgus), and average post-operative malalignment improved to 2.6◦ (range 0◦ varus to 7.9◦ valgus), but this difference was not statistically significant (p=.09). Average pre-operative sagittal malalignment was 8.7◦ (range 20.7◦ plantarflexion to 20.1◦ dorsiflexion), and average post-operative malalignment improved to 3.6◦ (range 8.3◦ plantarflexion to 9.3◦ dorsiflexion), which was statistically significant (p=.01). Talar height improved by 3.9mm (p< 0.001), and range of motion from 16.9◦ to 25.0◦ (p,0.001).

Conclusion:

At a minimum of two years of follow up, revision arthroplasty shows improved alignment, talar height, and range of motion. While the failure rate remains significantly higher than primary ankle arthroplasty, it is comparable or superior to that of conversion to arthrodesis. The complexity of RTTA varies greatly due to surgical risk, soft tissue quality, and residual bone stock amongst other factors, which limits the generalizability of this patient cohort. RTAA is a viable option for the salvage of failed primary TAA, with functional and radiographic improvements shown at mid-term follow-up.
Foot Loading Symmetry is Improved after Unicompartmental Knee Arthroplasty
Authors: LaBaze Dukens , Zarei Milad , Urish Ken , Anderst William , Hogan MaCalus V.
Published: November 2020

Category:

Basic Sciences/Biologics; Midfoot/Forefoot

Introduction/Purpose:

Unicompartmental Knee Arthroplasty (UKA) is a surgical option for osteoarthritis in a single compartment of the knee. Compared to Total Knee Arthroplasty (TKA), UKA is less expensive, retains the cruciate ligaments and results in lower post-operative morbidity.[1] It has been reported that about 10 percent of UKAs require revision to TKA for multiple reasons. In TKA, ankle alignment has demonstrated a significant effect on outcomes and function. [2] Plantar pressure, a measure of foot and ankle loading, changes after TKAs but has yet to be evaluated in UKAs. The purpose of this study is to evaluate the effects of medial UKA on plantar pressure which may be a variable that contributes to revisions in these patients.

Methods:

Following IRB approval and informed consent, we evaluated 7 adults (14 Feet) (average age 62; range: 54 to 68 years old; 4F/ 3M). All participants walked at a self-selected speed pre surgery and 7 months post-surgery. The Pedar insole pressure system (Novel), with 99 sensors per insole, was used to collect bilateral plantar pressure during gait at 100 Hz. All participants wore the same type of shoes (Nike Zoom) for the test. The insole was divided into 9 regions for analysis2 (Figure 1). The maximum pressure (MP) within each foot region was calculated for each step and averaged over all steps. Paired and unpaired t- tests were performed to identify differences in the MP from pre to post-op and between operated and contralateral sides, respectively.

Results:

An average of 24 steps were recorded from each patient pre and post operatively. MP became more symmetrical between feet post-operatively, with significant improvements in bilateral symmetry observed in the medial heel, medial and lateral forefoot regions (all p<0.01). The MP in the lateral midfoot region of the operative side increased during ambulation post- operatively (p<0.05). The MP in the lateral forefoot region of the non-operative side decreased post-operatively (p<0.01).

Conclusion:

Our results indicate that foot loading, as assessed through plantar pressure, becomes more symmetrical after unilateral UKA and may also affect non-operative foot loading. Although our sample size is small, our data is comparable with a similar study done in TKA patients which reported changes forefoot and lateral midfoot loading. [Table: see text]
Telemedicine Foot and Ankle Visits in the COVID-19 Era
Authors: Labib Sameh A. , Goel Rahul , Manz Wesley J. , Bariteau Jason T.
Published: November 2020

Category:

Other

Introduction/Purpose:

The current COVID-19 pandemic has created a unique problem for orthopaedic surgeons by mandating ‘social distancing’ and limiting patient-provider interactions. Centers have reacted to this by implementing Telemedicine as a way to still provide care for patients. We have developed a Telemedicine protocol we believe allows for enough information to be gathered to provide an accurate diagnosis and with high patient satisfaction.

Methods:

A 12-step standardized protocol was created to be used during foot and ankle Telemedicine visits. This was coupled with pre-visit preparation by the office staff with the patient as well as recommending appropriate follow-up either in person or again via Telemedicine. After implementation of this system in April 2020, we retrospectively reviewed Press-Ganey data collected for provider rating (scale 0-10) with Telemedicine visits and traditional office visits through June 2020. Scores of 9 and 10 out of 10 were grouped together to represent an excellent experience, and all other responses were grouped together as a less than excellent experience. Fischer’s exact test was used to compare samples.

Results:

A total of 183 patients were surveyed during this time period, 127 from telemedicine visits and 56 from in-office visits. 106/127 (83.4%) patients surveyed after Telehealth visits and 50/56 (89.2%) after in-person visits rated their visit as a 9 or 10 (p=0.37).

Conclusion:

The COVID-19 pandemic has changed the way that orthopaedic surgeons have needed to deliver care to their patients. Though the transition has had its difficulties, it would be a failure in progress to not recognize and adopt the advances that have been made during this time. Though the adaption of Telemedicine was made out of necessity at our institution, the lessons learned during this trying time has enabled us to provide excellent orthopaedic care through telemedicine that can continue once restrictions have been lifted.
Biomechanical Evaluation of Suture Button Spread with and without Deltoid Repair in Combined Syndesmosis and Deltoid Injury
Authors: Lau Brian , Storaci Hunter , Tam Kaysie , Lai Cara , Salazar Brett P. , Guzman Roberto , Oji David E. , Chou Loretta B.
Published: November 2020

Category:

Sports; Basic Sciences/Biologics

Introduction/Purpose:

Syndesmosis injuries are common and frequently occur with deltoid injuries but optimal repair remains controversial. Prior biomechanical studies have demonstrated that 1 and 2 suture buttons are equivalent to screw fixation and that parallel or divergent suture buttons are equivalent to single suture button. Prior studies, however, created constructs with suture buttons within 1cm from each other (2-3cm from joint surface). Additionally, the role of deltoid injury and repair have not been evaluated in conjunction with syndesmosis injury and repair. The purpose of this study was to biomechanically compare a narrow vs spread 2-suture button construct with and without a deltoid repair.

Methods:

Four matched lower leg specimens (8 total specimens) aged mean 60.2 years (range 57-66 years; 6 females and 2 males; mean BMI 21.1) were tested. Ankle motion under cyclic loading was measured in multiple planes: first in the intact state, following simulated syndesmosis and deltoid injury, then following fixation with 1 of 2 randomly assigned constructs: 2 parallel suture buttons at 2 and 3cm from joint line (narrow); and 2 parallel suture buttons at 1 and 4cm from joint line (spread), and then finally following a deltoid repair with each construct. Each state was tested at a constant 750 N axial compressive force and 5N internal/external torque. Rotation position (degrees) and anterior-posterior displacement (mm) were collected throughout the testing to characterize relative spatial relationships of the tibiofibular articulation using 3D video capture technology.

Results:

Narrow and spread 2-suture button constructs improved rotation and translation compared to cut state (p<0.05) but not to intact state (p>0.05). There were no significant differences in rotation or translation between Narrow and Spread constructs (p>0.05). The addition of a deltoid repair did not improve rotation or translation compared to syndesmosis repair with either construct alone (p>0.05).

Conclusion:

The preliminary results of this study suggest that constructs with suture button placed close together or spread apart during fixation of combined syndesmosis and deltoid injury could improve rotation and translation equally. Additionally, in a combined syndesmosis and deltoid injury, the addition of a deltoid repair to a syndesmosis repair did not strengthen the construct. These findings suggest that repair of syndesmosis alone may be sufficient in combined syndesmosis and deltoid injuries. Additional matched samples will be tested to validate preliminary findings.
Screw Fixation of the Posterior Malleolus Fragment in Ankle Fracture
Authors: Lee Gi-Soo , Song Jaehwang
Published: November 2020

Category:

Ankle; Trauma

Introduction/Purpose:

This study aimed to evaluate the outcomes of ankle fractures with posterior malleolus fragments (PMFs)involving <25% of the articular surface treated with or without screw fixation.

Methods:

Among patients with ankle fractures and PMFs who underwent surgery between March 2014 and February2017, 62 with type 1 PMFs involving <25% of the articular surface were included. Of these 62 patients, 32 underwent screw fixation for PMFs and lateral and/or medial malleolar fracture fixation (group A) and 30 underwent internal fixation for malleolar fractures without screw fixation for PMFs (group B). Ankle joint alignment and fracture healing were measured using plain radiography and computed tomography (CT). Clinical outcomes were determined using the American Academy of Orthopaedic Surgeons Foot and Ankle Questionnaire, Short Form-36, and American Orthopaedic Foot & Ankle Society Scale.

Results:

Nonunion was not noted in either group. However, we detected union with a step-off of 2 mm or more in2 cases from group B. With regard to ankle joint alignment, 1 case in group A and 3 cases in group B showed mild asymmetry of the medial and lateral clear spaces on CT at 12 months. Clinical outcomes at 6 and 12 months after surgery were better in group A than in group B.

Conclusion:

Screw fixation of PMFs was effective for fracture healing and maintaining ankle alignment. Additionally, it improved short-term clinical outcomes, which we believe was due to stabilization of ankle fractures with PMFs involving <25% of the articular surface.
Clinical Outcome of Bimalleolar Ankle Fracture in Patients with Diabetes Mellitus
Authors: Lee Hong S. , Young Kiwon , Park Tae-Hoon , Lee Hong Seop
Published: November 2020

Category:

Trauma; Ankle

Introduction/Purpose:

Diabetes is a risk factor of postoperative complication for fracture surgery. The purpose of this study was to evaluate the clinical outcome of bimalleolar ankle fracture in patients with diabetes mellitus.

Methods:

Twenty two patients (an average age; 69.3 years, an average HbA1C; 7.6%) with bi-malleolar ankle Fracture received open reduction and internal fixation between March 2013 and January 2019. Complications related to surgery, progression to Charcot arthropathy, presence of nonunion were used for outcome analysis. The patients were followed for an average of 12.1 months.

Results:

The nonunion rate was 4.5% (1 case over 22 cases). The incidence rate of Charcot arthropathy was 4.5% (1 case over 22 cases). The patient with Charcot arthropathy was conversed to the tibiotalarcalcaneal fusion with retrograde intramedullary nail. No wound infection or soft tissue complications related to surgery was reported.

Conclusion:

Standard open reduction and internal fixation technique showed high union rate of bimalleolar ankle fracture in patients with diabetes mellitus. The surgeon should be cautious to the Charcot arthropathy when treating ankle fracture with diabetes mellitus.
Comparison of Open Syndesmotic Repair and Trans-syndesmotic Screw Fixation: A Biomechanical Study
Authors: Lee Hong S. , Young Kiwon , Park Tae-Hoon , Lee Hong Seop
Published: November 2020

Category:

Trauma; Ankle

Introduction/Purpose:

We hypothesized that open syndesmotic repair for ankle syndesmotic injury would provide adequate strength. The purpose of this study was to compare the biomechanical properties of open syndesmotic repair with those of screw fixation.

Methods:

Ten matched pairs of human cadaver specimens were subjected to open syndesmotic repair or screw fixation. Each specimen underwent initial intact physiologic loading, consisting of 10 cycles of external torsional loading with a peak torque of 7.5 Nm at 0.05 Hz. Post-fixation cyclic loading consisted of 50 cycles of combined axial and external rotation loading with peak torques of 750 N and 7.5 Nm at a rate of 0.05 Hz. After post-fixation loading, each specimen underwent failure loading by external rotation at 0.25 degrees/second. Failure was defined as a sudden decrease in the torque-degree curve. Failure torque and failure angle were measured. The paired t-test and Wilcoxon signed-rank test were used to analyze the data.

Results:

Mean failure torques were 95.63 Nm in the open syndesmotic repair group and 108.61 Nm in the screw group. Mean failure angles were 34.93 degrees in the open syndesmotic repair group and 43.55 degrees in the screw group. These data were not statistically significantly different between the two groups (p = 0.7682 and 0.4133, respectively).

Conclusion:

Open syndesmotic repair for ankle syndesmotic injury provides similar torsional strength to that of screw fixation. Therefore, this technique can be considered as an alternative treatment option for syndesmosis injury.
Return to Play after Open Repair for Achilles Rupture in Recreational Athletes
Authors: Lee Hong S. , Young Kiwon , Park Tae-Hoon , Lee Hong Seop
Published: November 2020

Category:

Sports

Introduction/Purpose:

The management of Achilles tendon ruptures in recreational athletes can be challenging. This study assessed the average time to return to sport after open repair for Achilles rupture in recreational athletes.

Methods:

Twenty one recreational athletes with prodromal tendinous problems sustained an acute tear of the AT and surgical repair with Krachow method from June 2013 to April 2017. Their average age was 39.7 years, and the average follow-up time was 53.2 months. Each patient was evaluated for postoperative ATRS (Achilles Tendon Total Rupture Score), complication and time to return to sports.

Results:

The mean postoperative ATRS was 85.1. The mean length of time to return to sports was 8 months. Eighteen patients of 21 athletes returned to full sport participation. Eleven athletes returned to the original sports. Seven athletes changed their sports due to fear of re-rupture (four athletes), discomfort during running or jumping (one athlete), general weakness (one athlete), dissuade of family (one athlete). Three athletes didn’t return to sport participation due to thickening of Achilles tendon (two athletes) and personal reason (one athlete).

Conclusion:

The return to play was 85 % at 8 months postoperatively. The results provide reference data for sports physician in evaluation surgical results and informing athletes about expectations after surgery in terms of timing of return to sports in recreational athletes.
Appropriate Distraction Strength of Metatarsopahlangeal Joint Arthroscopy
Authors: Lee Kwang-Bok , Kim Jongkil
Published: November 2020

Category:

Arthroscopy; Bunion; Lesser Toes

Introduction/Purpose:

Appropriate distraction for metatarsophalangeal joint arthroscopy is paramount to increase in visualization and to decrease iatrogenic complications. However, there are few studies on how much adequate distraction is. The purpose of this study was to investigate the appropriate degree of distraction and the associated factors.

Methods:

40 patients who underwent toe arthroscopy from April 2015 to June 2018 were enrolled. Under general or spinal anesthesia, the anterio-posterior foot plain radiograph were taken using mini-fluoroscan; no traction, manual traction, 5, 10 and 15 pound traction and were used to measure the metatasophalangeal joint (MTP) distance. Age, gender, body mass index were compared as associated factors. The minimum joint distance of toe arthroscopy defined as 2.8mm which was sheath size of 1.9mm 30° high definition arthroscopy. Appropriate distraction is defined as an over 70% possible rate.

Results:

10lb traction was appropriate distraction on first and fourth MTP joint arthroscopy. 5lb traction was appropriate on second, third, fifth MTP. In first MTP with 5lb traction, there was significant difference according to gender; 9 of 23 male, none of 17 female. (p=0.005). With 10lb traction, 16 of 27 patients under 60 and 3 of 13 patients over 60 years old were could arthroscopy (p=0.046). In third MTP with 5lb traction, 18 of 28 patients over 30 were could arthroscopy, but only 4 of 13 under 30 years old were could(p=0.038). In fourth MTP with 5lb traction, there was significant difference according to gender, male (12 of 23 patients) was had arthroscopy, but only 2 of 17 female patients. (p=0.017).

Conclusion:

In the MTP joint arthroscopy, 10lb was needed in first and fourth MTP joint, and 5lb was needed in second, third, fifth MTP joint. Manual traction is generally not appropriate for distraction. Female and under 60 years old patients needed more distraction in first toe arthroscopy. Under 30 years old patients in third toe and female patients in fourth toe arthroscopy needed more distraction than 5lb. [Table: see text]
Fracture Type, Postoperative Articular Congruency and Obesity of Patients Influenced on Long to Midterm Outcome of Posterior Malleolar Fractures in Ankle Injury
Authors: Lee Sung Hyun
Published: November 2020

Category:

Trauma; Arthroscopy

Introduction/Purpose:

One of the factors contributing to outcome of posterior malleolar (PM) fractures is the development of osteoarthritis. Previous studies suggested that fragment size of PM and postoperative articular congruency were influenced on generative ankle arthritis. Haraguchi et al. classify PM fractures according to pathoanatomy of injury. However, there was no study to investigate possible risk factors including the type of PM fracture for degenerative arthritis in ankle fractures including PM. The purpose of this study was to identify the risk factors for degenerative arthritis in ankle fractures including PM. We hypothesized that risk factors for posttraumatic arthritis could be identified from patient demographic and the extent of the pathologic condition associated with fractures.

Methods:

We performed a retrospective review between 2004 and 2015 of consecutive patients who underwent operation with ankle fractures and available at minimum 5 years of follow up. The exclusion criteria included diabetic neuropathy, skeletal immaturity, tibial pilon fractures, polytrauma, open fracture. Patients were sorted into 2 groups according to the presence of arthritis change more than grade 2 at last follow up. Furthermore, the statistical analysis by binary logistic regression analysis included the significance of various risk factors including age at surgery, sex, diabetes, smoking, body mass index (BMI), dominant side, time interval between the trauma and surgery, type of PM fracture, PM fragment size and postoperative joint congruency, The functional outcomes were assessed with the Foot and Ankle Outcome Score (FAOS).

Results:

A total 332 patients with mean follow up of 8.2+-2.4 years met the study inclusion criteria and underwent analysis. The overall rate of posttraumatic arthritic change was 31.3% (non-arthritis group: 228 patients, arthritis group: 104). It was significantly affected by the BMI (p=0.021; adjusted odds ratio, OR, >= 30, 7.23), Mason classification type 3 PM fracture (p=0.031, adjusted OR 4.23), >25% of articular surface of PM, and postoperative articular incongruence (p=0.029, adjusted OR 5.13). The other variables were not found to be significant risk factors. The mean scores in the group with arthritis were significantly lower than those in the group without arthritis (p=0.001)

Conclusion:

The overall results suggest that articular congruency should be considered during surgery along with meticulous attention to anatomic reduction of large fragment posterior malleolar fracture, especially in obese patients.