bluuebunny/crossref_metadata_2025 huggingface dataset:
Impact of Early Weight Bearing on Outcomes after Open Reduction and Internal Fixation of Trimalleolar Ankle Fractures
Authors: Myers Devon , Umbel Benjamin D. , Forsting Shane , Taylor Benjamin C. , Pulido Sergio H.
Published: November 2020

Category:

Ankle; Trauma

Introduction/Purpose:

There is a current trend to allow earlier weight-bearing of unstable ankle fractures after fixation. This study offers a unique comparison of early (EWB) versus late weight-bearing (LWB) in operatively stabilized trimalleolar ankle fractures. The purpose of this study was to evaluate union rates, clinical outcomes and complications in patients managed with EWB versus LWB.

Methods:

We performed a retrospective review of 185 patients with trimalleolar ankle fractures who underwent surgical stabilization. Fixation of the posterior malleolus and weight-bearing status were determined by surgeon preference. EWB was defined as ≥3 weeks and LWB was defined as >3 weeks. Patients were evaluated for fracture union and implant failure. Complications and clinical outcomes included ambulatory status, infection rate and return to surgery.

Results:

There were 47 (25.4%) patients in the EWB group and 138 (74.6%) in the LWB group. There were 7 nonunions, 1 (14.3%) in the EWB and 6 (85.7%) in the LWB group. Seventy-two (38.9%) posterior malleolar fractures were operatively stabilized which did not affect union rates. Syndesmotic fixation was required in 12.5% of patients despite posterior malleolar stabilization. Syndesmotic fixation increased union rate 2.5 times. Deep infection and open fracture decreased union. There was no difference in implant failure, union rate, infection or return to surgery between groups.

Conclusion:

No deleterious effect of EWB of operatively treated trimalleolar ankle fractures were found with regards to union, implant failure, infection or reoperation. Syndesmotic fixation may offer an advantage to posterior malleolar fixation with improved union rates.
Ability to Show the Knuckles in Forefoot Helps to Assess Intrinsic Muscle Function
Authors: Panchbhavi Vinod K. , Poliner Michael , Finegan Patrick , Jupiter Daniel
Published: November 2020

Category:

Midfoot/Forefoot; Lesser Toes

Introduction/Purpose:

The plantar plate stabilizes the metatarsophalangeal joint (MTPJ). When the plantar plate is disrupted the static forces resisting the strong extensor muscles are compromised, overwhelming the intrinsic muscles of the foot resulting in toe deformities. The proposed ‘knuckle test’ is a clinical exam to evaluate for intrinsic muscle weakness. Patients with negative knuckle tests are unable to plantar flex their toes at the MTPJ to prominently display the knuckles. This study seeks to determine the prevalence of negative knuckle tests in patients with and without associated toe deformities.

Methods:

This is an observational case-control study to compare the prevalence of a negative knuckle test in participants with evidence of toe deformities or plantar plate incompetence based on physical exam findings (case group) to participants with normal feet (control group), defined as no signs or symptoms of a current or past plantar plate tear. A participant will qualify for the case group if they have a positive MTPJ drawer test or an associated toe deformity (medial deviation, hyperextension of the MTPJ, floating toe, hammer toe deformity, or crossover toe). The participants will also complete a short survey to identify factors associated with plantar plate injuries such as BMI, gender, age, smoking history, diabetes, sports history, injury history, heel or boot wear, hyper flexibility, and collagen disorders.

Results:

The research team has gathered 75% of the participant data. Preliminary data shows that the majority of participants in both groups have negative knuckle tests. The final results will be analyzed once all the data has been collected.

Conclusion:

The percentage of negative knuckle test in patients without toe abnormalities or symptoms was unexpectedly high. The implication is that there is a high incidence of weak intrinsic foot muscles. Foot intrinsic muscle exercises may help to prevent toe deformities. Other findings will be interpreted after all data has been collected.
Surgical Management of Insertional Achilles Tendinopathy in the Young and Elderly Result in Similar Clinical Outcomes
Authors: Phen Huai M. , Manz Wesley J. , Greenshields Joel T. , Mignemi Danielle , Bariteau Jason T.
Published: November 2020

Category:

Other; Ankle

Introduction/Purpose:

Insertional Achilles tendinitis (IAT) is a common cause of chronic posterior heel pain. Non-operative treatment has demonstrated evidence of success, with similar failure rates in both the young and the elderly. Surgical management can reproducibly improve patients’ pain and functional status. Older patients are considered to be at a higher risk for surgical complications due to associated comorbidities when compared to patients under the age of 60. The aim of this study is to investigate the impact of comorbidities and peri-operative variables on functional patient reported outcomes following surgical treatment of IAT in those over and under the age of 60.

Methods:

Retrospective review of prospectively collected data pertaining to a consecutive series of adult patients who underwent surgical management of IAT by a single surgeon (J.B.). Patients were separated into those 60 years of age and younger, and those above 60. Patients undergoing concomitant surgical procedures or revisions were excluded. Patient demographics, co- morbidities, perioperative variables, and post-operative complications were collected. Visual Analogue Scale (VAS), Short Form Health Survey Physical Component Score (SF-36 PCS), wound infection, and recurrence were assessed with a minimum follow-up of 12 months. Statistics were obtained using linear regression mixed models, and chi-squared analysis.

Results:

38 operative cases were identified including 17 patients over and 21 patients under 60 years of age (mean 66.8 +/- 5.1yrs, 49.1 +/- 8.4yrs, respectively). There were no significant differences in demographics, rates of co-morbidities, or post-operative infection between the two groups. Both young and elderly groups experienced improvements in mean VAS pain scores at 6 months (3.3 and 2.7, respectively, P = 0.416) and 12 months (5.0 and 4.1, respectively, P = 0.322) post-operatively. SF-36 PCS improvements were also observed in both young and elderly cohorts at 6 (mean 22.1 and 9.3, respectively, P = 0.122) and 12 months (mean 30.4 and 20.4, respectively, P = 0.158). Linear regression analysis showed no statistical difference between the presence of co-morbidities, or age, on clinical outcomes.

Conclusion:

None of the co-morbidities nor peri-operative variables assessed were linked to increased risk of failed surgical correction of IAT in elderly patients, suggesting surgical correction of IAT in geriatric populations is an appropriate and reproducible treatment option. Further higher-powered studies, with longer follow-up times would be of use to better elucidate the influence of co-morbidities on recurrence.
Exposure of the Calcaneus via the Sinus Tarsi Approach versus the Lateral Extensile Approach: A Cadaveric Study
Authors: Prather John C. , Wilson John , Abyar Eildar , Young Sean , McGwin Gerald , Johnson Michael D.
Published: November 2020

Category:

Hindfoot; Trauma

Introduction/Purpose:

The lateral extensile approach (LEA) to the calcaneus has long been a popular surgical approach to treat calcaneal fractures. However, high rates of wound complications have led surgeons to investigate alternative approaches. As a result, the sinus tarsi approach has grown in popularity. The lateral extensile approach affords substantial visualization of the calcaneus. However, this visualization has never been compared in a quantitative manner to the sinus tarsi approach (STA). The objective of this cadaveric study is to compare calcaneal visualization afforded by a sinus tarsi approach and a lateral extensile approach.

Methods:

Seven pair-matched, fresh-frozen, below-knee cadaver specimens were obtained. For each pair, one side received an LEA and the other side received a STA. To identify areas of the calcaneus accessible by instrument, a curette was used to mark the visualized calcaneal surfaces. The calcaneus was then disarticulated and cleared of all soft tissue. The curette markings were then identified and marked with blue surgical marker. Photos were taken of each calcaneus, and visualized surface areas were calculated using Image J software.

Results:

There were no statistically significant differences in the articular surfaces accessible between the two approaches (831.99 mm2 for LEA vs. 903.41 mm2 for STA, p=0.53) including the anterior, middle, and posterior facets. The total calcaneal surface area accessible was 3107.08 mm2 for LEA and 1444.19 mm2 for STA (p=0.02). The LEA allowed better exposure to the lateral wall (p<0.01) and superior greater tuberosity of the calcaneus (p=0.05).

Conclusion:

In comparison to the LEA, the STA allows for equivalent exposure to articular surfaces. While the LEA allows for greater exposure of the lateral wall and posterior tuberosity, direct visualization of these structures may not warrant the higher risk of wound complications. Surgeons should be mindful of these differences when choosing a surgical approach in the treatment of calcaneal fractures.
Combined Suspensory and Aperture Fixation of Posterior Tibialis Tendon Anterior Transfer for Dropfoot
Authors: Ray Robbie , Navratil Richard , Ogilvie Andrew , Lewis Thomas L.
Published: November 2020

Category:

Other; Trauma

Introduction/Purpose:

Anterior transfer of the tibialis posterior tendon (TPT) can restore ankle dorsiflexion in patients with foot drop. A limitation of this procedure is the need for postoperative ankle immobilisation. We present the results of a novel dual method of TPT docking which infers immediate stability, allowing early weightbearing.

Methods:

8 patients underwent 9 tendon transfers,age range of 28-52 years. 3 patients had dropfoot from common peroneal nerve injury, 6 cases were part of a complex cavovarus or spastic equinovarus correction. The TPT is passed to the dorsum of the foot through the interosseous membrane. The docking site is prepared with a bicortical pilot hole followed by unicortical overreaming. The TPT is whipstitched and an Arthrex biceps button is threaded to the sutures. The button is passed bicortical and flipped using a tension slide technique give stable suspensory fixation. Additional stability is conferred by overpassing an Arthrex biotenodesis screw giving aperture fixation. Patients are immobilised in a boot and allowed to weightbear immediately.

Results:

Follow up was 6 months. There was difficulty in docking of suspensory fixation in two of the early cases. These patients had aperture fixation and were immobilised non weightbearing in a cast for 6 weeks. With technical modifications, all subsequent patients had dual fixation. At 6 months there were no radiological or clinical failures of fixation. Patients without other underlying issues were able to mobilise splint free at 6 months. All patients were satisfied with their procedure.

Conclusion:

Aperture fixation with an interference screw has become the gold standard for TPT transfer, however, patients still need a prolonged period of immobilisation. Combined suspensory and aperture fixation is technically straightforward and seems to give more initial stability allowing early weightbearing. Further prospective studies and biomechanical studies are needed to validate this technique.
Correction of Valgus Lesser Toes by Percutaneous Closing Wedge Osteotomy of the Proximal Phalanx
Authors: Ray Robbie , Robinson Peter W. , Dearden Paul M. , Goff Thomas A. , Lam Peter , Lewis Thomas L.
Published: November 2020

Category:

Lesser Toes; Bunion

Introduction/Purpose:

Deformities of the lesser toes are usually described in the sagittal plane. Coronal plane deviation is also common, yet there is a paucity of literature on the management of these challenging deformities. Traditional soft tissue procedures and translational Weil osteotomies are unpredictable and can lead to post-operative stiffness. We present the results of a novel percutaneous osteotomy of the proximal phalanx to treat valgus deformity of the 2nd toe.

Methods:

29 patients underwent 38 osteotomies at a mean age of 59+/-9 years. Through a 2mm dorsomedial incision, a percutaneous proximal metaphyseal medial closing wedge osteotomy is performed using a low speed, high torque 2x8mm burr. The toe is then taped for 2 weeks. Mean follow up was 29+/-18 months. Post-operative weight bearing radiographs were performed at a mean of 27+/-18 months. Dichotomous variables were assessed using a Chi square test. After confirming normality using a Kolomgrov-Smirnov test, continuous variables were measured using paired and independent t-tests.

Results:

90% (n=26) patients responded. 88% (n=23) patients were satisfied or extremely satisfied with the procedure. 24% reported a partial (n=4) or complete recurrence (n=2) of deformity. Patients who perceived recurrence were significantly more likely to be dissatisfied (p=0.001). Radiographs were available for 27/38 osteotomies. Mean valgus angle decreased from 21+/-10° to 9+/-8° (p=0.001). All osteotomies united with no delayed union. There were no wound complications or infections. 2 patients reported long term numbness in the toe and 1 patient complained of a floating toe.

Conclusion:

Percutaneous closing wedge osteotomies to correct (valgus)coronal plane deformity is technically straight forward with a low complication rate and high patient satisfaction. Future studies should assess the role of this technique to correct medial crossover deformities and compare outcomes with other techniques.
Long-Term Follow up of Correction of Moderate to Severe Deformity with the STAR Ankle Prosthesis
Authors: Reddy Sudheer C. , Mann Roger A. , Zemeir Kyle , Reddy Sudheer C.
Published: November 2020

Category:

Ankle Arthritis

Introduction/Purpose:

Addressing coronal plane deformity when performing a total ankle arthroplasty (TAA) remains a topic of controversy. While surgeons have become bolder in correcting deformity, long-term follow-up is sparse regarding maintenance of correction and viability of the prosthesis. The purpose of this study is to assess the long-term follow up of the correction of moderate to severe coronal plane deformity with the use of a mobile bearing prosthesis.

Methods:

Out of a consecutive series of 130 patients who underwent TAA between 2000 and 2009, 43 patients (44 ankles) had at least 100 of tibiotalar coronal plane deformity, with 25 having between 100 and 200 of deformity and 18 having greater than 200. Average age at time of the index surgery was 66 yrs (range 41-79). Initial deformity was 17.90 (range 10-290) in the entire cohort. All patients underwent intraarticular deformity correction with intraoperative soft-tissue balancing as indicated utilizing the STAR prosthesis. Patients requiring realignment osteotomies were performed in a staged fashion prior to undergoing TAA.

Results:

Seven patients (16%) were available for long-term follow up (avg 13 yrs; range 9-16 yrs) with retention of the original prosthesis, two of which had greater than 200 of initial deformity. Average final tibiotalar deformity was 4.90, with a mean correction of 130(p=0.0001). No additional procedures related to the prosthesis were performed. Eleven patients (12 ankles) were deceased at the time of the study due to unrelated conditions. Of the original cohort, five were deemed failures (2 converted to arthrodesis; 2 underwent component revision; 1 polyethylene fracture) and excluded from long-term follow up. The remaining 20 patients were lost to follow-up, had declined or were unable to participate due to health status.

Conclusion:

While the low follow-up rate limits the overall generalizability of the results, enduring correction of moderate and severe coronal plane deformity with a mobile bearing prosthesis can be achieved in a cohort of patients traditionally regarded as high-risk. One must be cautious when discussing with patients the utilization of TAA in the setting of moderate and severe coronal plane deformity given the risk of failure. However, provided a well-balanced ankle can be achieved intraoperatively, long-term mobile bearing prosthesis survivorship is achievable.
Impact of Preoperative Metatarsus Adductus on Surgical Correction after Triplanar Tarsometatarsal Arthrodesis
Authors: Reside Joshua M. , Ray Justin J. , Shackleford Taylor L. , Koay Jennifer , Dayton Paul , Hatch Daniel J. , Smith W. Bret , Santrock Robert D.
Published: November 2020

Category:

Bunion; Midfoot/Forefoot

Introduction/Purpose:

Early radiographic outcomes of hallux valgus correction focusing on multiplanar deformity have shown promising results. Surgical correction for patients with preexisting metatarsus adductus is considered more challenging and results in higher recurrence rates following hallux valgus surgery. The purpose of this study was to evaluate the impact of preoperative metatarsus adductus on surgical correction following triplanar first tarsometatarsal (TMT) arthrodesis with early weightbearing for hallux valgus.

Methods:

A retrospective review was performed of 57 patients (62 feet) aged 39.7 +- 18.9 years who underwent triplanar first TMT arthrodesis between 2015 and 2017 at four institutions. After the operation, patients were allowed early full weightbearing in a walking boot. Patients were grouped based on preoperative metatarsus adductus angles for comparison. Preoperative imaging was reviewed and compared to radiographic imaging at 12 months postoperative. Hallux valgus angle (HVA), intermetatarsal angle (IMA), tibial sesamoid position (TSP), lateral round sign, and sesamoid subluxation (axial) were evaluated. For statistical analysis, one-way analysis of variance (ANOVA) and chi-square tests were performed using JMP 11.0.0 (SAS Institute Inc., Cary, NC).

Results:

Patients with a preoperative metatarsus adductus angle greater than 20 degrees had significantly higher HVA at 12 months (p = 0.0165). There were no differences in IMA or TSP at 12 months based on preoperative metatarsus adductus (p = 0.7687 and p = 0.8703, respectively). Overall recurrence rate for hallux valgus was 3.2% (2/62 patients), and both of these patients had a preoperative metatarsus adductus greater than 20 degrees. There was significantly more sesamoid axial subluxation at 12 months for patients with preoperative metatarsus adductus greater than 20 degrees (p = 0.0092). Overall, the symptomatic non- union rate was 1.7% (1/62 patients).

Conclusion:

Preoperative metatarsus adductus greater than 20 degrees resulted in higher HVA and recurrence rates at 12 months after triplanar tarsometatarsal arthrodesis. For patients with preexisting metatarsus adductus, additional consideration should be given to ensure the sesamoids are properly reduced under the crista. Future studies should compare the long-term impact of metatarsus adductus on surgical correction, recurrence, and complications after triplanar tarsometatarsal arthrodesis.
Early Failures of Polyvinyl Alcohol Hydrogel Implant for the Treatment of Hallux Rigidus
Authors: Rosas Kevin , Hurley Eoghan T. , Kennedy John G.
Published: November 2020

Category:

Midfoot/Forefoot; Basic Sciences/Biologics

Introduction/Purpose:

A polyvinyl alcohol hydrogel implant (Cartiva Synthetic Cartilage Implant) has recently been developed, which has a water content comparable to healthy cartilage and a compressive modulus and tensile strength similar to human articular cartilage. These biomechanical features have been thought to be an ideal material for use in hemiarthroplasty of the first MTP joint. The purpose of this study is to evaluate the clinical, functional and radiological outcomes following a polyvinyl alcohol hydrogel implant for the treatment of hallux rigidus.

Methods:

A retrospective cohort study investigating patients treated with polyvinyl alcohol hydrogel implant for hallux rigidus was performed. Patients who had grade 2, 3 or 4 hallux rigidus based on Coughlin classification were indicated. Clinical outcomes were evaluated with the Foot and Ankle Outcomes Score (FAOS) and Visual Analog Score (VAS) preoperatively and at final follow-up. Plain radiographs were assessed postoperatively at 2, 4, 8 weeks and final follow-up.

Results:

Fifteen patients (15 feet) with mean follow-up of 19.0 months (12-26 months) were included. The mean age was 61.1 years. FAOS-reported symptoms, pain, daily activities, sports activities, and quality of life were 62.3, 69.8, 74.5, 49.7, and 36,3 post-operatively, respectively. Of 14 patients who had taken adequate postoperative plain radiographs, implant subsidence was observed in 9 patients (64%) at 4 weeks after surgery and 11 patients (79%) at final follow-up. . Eight patients (57%) showed radiologic lucency around the implant. Six patients (40%) had erosion of the proximal phalanx of great toe. Six patients(43%) reported no improvement following surgery at final follow up. Three patients required additional surgery, including debridement and fixation of implant using fibrin glue for loosening.

Conclusion:

Our current study revealed a high failure rate with the polyvinyl alcohol hydrogel implant in patients with Hallux Rigidus. Significant radiologic subsidence with lysis around the implant, erosion of the proximal phalynx countersurface as well as recorded implant wear are harbingers for concern in the long term.
Total Ankle Arthroplasty (TAR) vs. Ankle Arthrodesis (AA) for Primary Ankle Osteoarthritis: A Nationwide Analysis
Authors: Ross Bailey J. , Savage-Elliott Ian , Wu Victor , Rodriguez Ramon F.
Published: November 2020

Category:

Ankle Arthritis; Ankle

Introduction/Purpose:

Ankle arthrodesis (AA) has historically been the gold standard for operative management of end-stage ankle osteoarthritis (OA). Recent increases in utilization of total ankle arthroplasty (TAR) have been observed secondary to new implant designs, improved surgical technique, and favorable functional outcomes. However, there is minimal data comparing clinical complications between the two procedures. The purpose of this study was to compare incidences of postoperative joint and systemic complications for patients that received primary AA vs. TAR for primary ankle osteoarthritis between 2007-2017 using a comprehensive Medicare database.

Methods:

A retrospective review of patients that received primary AA or TAR was performed using the PearlDiver database (Fort Wayne, IN). All patients and associated complications were identified using ICD-9/ICD-10 and CPT codes. Patients with a history of ankle fracture, prior AA/TAR, or active ankle infection during the index procedure were excluded. Demographic data and overall joint complication rates were compared at 90-days, 1-year, and 2-years postoperatively using a Chi-Square test. Postoperative rates of subtalar fusion, prosthetic joint infection, hardware removal, periprosthetic fracture, and systemic complications were compared using logistic regression. Statistical significance was set at p < 0.05.

Results:

A total of 1,580 patients received operative management of primary ankle OA: 1,100 (70%) patients received AA and 480 (30%) patients received TAR. The overall joint complication rate was higher in the AA group at 90-days (30% vs. 17%, p < 0.001), 1-year (36% vs. 21%, p < 0.001), and 2-years (38% vs. 22%, p < 0.001) post-discharge. AA patients were more likely to have a subsequent subtalar fusion at 90-days (OR 4.49), 1-year (OR 5.10), and 2-years (OR 5.36) post-discharge, as well as periprosthetic fracture at 1-year (OR 1.69) and 2-years (OR 1.77). Hardware removal was less likely for AA patients at 90-days (OR 0.43), 1-year (OR 0.41), and 2-years (OR 0.43). Neither group was more likely to develop systemic complications postoperatively.

Conclusion:

The present study found that AA patients have higher incidences of major joint complications in both the short- term and mid-term. Patients that received AA were more likely to have a subsequent subtalar fusion and sustain a periprosthetic fracture. Relative to TAR patients, a greater proportion of these patients were under the age of 65, obese, had diabetes, and used tobacco. TAR patients were more likely to have hardware removal post-discharge. Further study is warranted to better quantify patient selection for AA vs. TAR and trend the long-term complications of these procedures.
Comparative Outcomes and Complications of Open versus Endoscopic Gastrocnemius Recession: A Prospective Randomized Control Trial
Authors: Rungprai Chamnanni , Sripanich Yantarat , Pongpinyopap Warongporn
Published: November 2020

Category:

Other

Introduction/Purpose:

Both open and endoscopic gastrocnemius recession are commonly used for treatment of gastrosoleus contracture, however; there was a paucity of evidence in literatures to compare post-operative outcomes between the two techniques. The purpose of this study is to compare outcomes and complications between open and endoscopic techniques.

Methods:

A prospective, randomized collected data of 53 consecutive patients who were diagnosed with gastrosoleus contracture and underwent either open (26 patients) or endoscopic (27 patients) gastrocnemius recession between 2016 and 2018. The primary outcome was ankle dorsiflexion and secondary outcomes were visual analogue scale (VAS), Short Form-36 (SF- 36), FAAM, plantarflexion weakness, operative times, and complications.

Results:

There were 53 patients with mean age of 49.1 years, mean BMI of 26.5 kg/m2, and mean follow-up of 11.5 months. Both techniques demonstrated significant improvement of ankle dorsiflexion (12.1 vs 11.3 degrees, p<0.001) and all functional outcomes (FAAM, SF-36, and VAS (p<0.001 all)); however, there was no significant difference between the two groups, (p>0.05 all). In addition, there were significant shorter operative times in endoscopic technique (7.3 vs 18.7 minutes, p<0.01). Complications included wound complications (3.8 vs 0%), painful scar (7.7 vs 0%), sural nerve injury (3.8 vs 0%), and plantarflexion weakness (3.8 vs 3.8%) for open and endoscopic techniques respectively.

Conclusion:

Both open and endoscopic techniques were demonstrated significant improvement of post-operative outcomes as measured with ankle dorsiflexion, FAAM, SF-36, and VAS. Although the post-operative outcomes were not significantly different between the two groups, the endoscopic technique demonstrated lesser complications and shorter operative times.
Comparison of Syndesmotic Malreduction Rate following Trans-Syndesmotic Screw Fixation in SER versus PER Type Ankle Fracture: A Prospective Analytic Study
Authors: Rungprai Chamnanni , Sripanich Yantarat
Published: November 2020

Category:

Ankle; Trauma

Introduction/Purpose:

Syndesmotic injury frequently presents in severe rotational ankle fracture and a trans-syndesmotic screws fixation is commonly used technique. Bases on previous literatures, syndesmotic malreduction rate can occur between 20- 70 percent following traditional trans-syndesmotic screw fixation in all type of ankle fracture. However, there is a little evidence regarding the malreduction rate in each type of ankle fractures. The purpose of this study is to demonstrate malreduction rate of syndesmosis using simultaneously bilateral post-operative CT measurement after trans-syndesmotic screw fixation between supination external rotation and pronation external rotation type ankle fracture.

Methods:

A prospective comparative study of patients who had acute ankle fracture with syndesmotic injury between January 2015 and December 2017 were enrolled. Lague-Hansen classification was used to classify all patient into 2 groups: SER and PER based on mechanism of injury. Syndesmotic injury was confirmed by ankle arthroscopic examination in all patients and they were treated with ORIF distal fibula using either 1/3 tubular plate or anatomical locking plate under direct visualization of syndesmosis. Syndesmosis was fixed by one or two of 3.5-mm cortical screw with three or four cortices. The accuracy of syndesmotic reduction was evaluated by simultaneously bilateral post-operative CT scan. Syndesmotic reduction was measured using anterior to posterior distance (AP) and medial to lateral distance (ML). A widening of distance between anterior tibia and fibula at 1-cm above the ankle joint more than 2 mm compared to uninjured sides considered a malreduction of syndesmosis.

Results:

There were 67 patients were enrolled in this study (SER=48 and PER=15). The syndesmotic injury was present 60% (48/70) in SER and 100% (15/15) in PER group respectively. The malreduction was significant higher in PER than SER (2.1% in SER vs 20% in PER). Operative time was 58.2 and 79.2 minutes in SER and PER. The tibiofibular clear space was 4.0mm versus 4.8mm in SER and PER. The AP distance was -0.33mm and -0.51mm and ML distance was 1.91 mm and 1.59mm for SER compared to normal side and 0.19 mm and -0.21 and ML distance was 2.59mm and 1.63mm for PER compared to normal side. There were significant improvements of functional outcomes (FAAM, SF-36, and VAS) but no significant different between the two groups.

Conclusion:

The incidence of concomitant syndesmotic injury and syndesmotic malreduction rate following trans-syndesmotic screw fixation was significantly higher in PER type compared SER type ankle fracture. The malposition of distal fibula was displaced anteriorly and laterally (undercompression) compared to uninjured side.
Outcomes and Complications Following Treatment of Chronic Subtle Syndemotic Injury with Arthroscopic Debridement and Fixation with Suture Button
Authors: Rungprai Chamnanni , Sripanich Yantarat
Published: November 2020

Category:

Ankle; Arthroscopy

Introduction/Purpose:

The syndesmotic injury can be occurred 10-18 percent associated with acute ankle sprain. This injury is commonly missed due to a difficulty to diagnosis in acute setting leading to chronic pain, swelling, and inability to return to previous level of activities and sports. Anterior ankle arthroscopic examination has been proposed to be successful technique to establish the diagnosis of this subtle injury. The purpose of this study is to demonstrate outcomes and complications of the patients who isolated syndesmotic injury and treated with anterior ankle arthroscopic debridement and fixation with suture button.

Methods:

A prospective case series of 62 patients who had ankle sprain with chronic pain on syndesmosis between 2015 and 2019 were enrolled in this study. All patients were failed from conservative treatment including bracing, ankle range of motion and strengthening exercises, low-does laser, and ultrasound treatment for at least 6 months after initial injury. The syndesmotic injury was considered when patients had chronic pain and swelling and athletic taping test was positive, and MRI demonstrated AITFL torn or fluid was ascended more than 10mm from ankle joint line. All patients were confirmed by intra-operatively ankle arthroscopy with a 3-mm shaver could pass through the syndesmotic joint. Syndesmotic joint was debridement and was fixed by suture button. Pre- and post-operative SF-36, FAAM, and VAS were obtained and compared using a paired t-test. Operative times, complications, and recovery times including time to return to ADL, work, and sports were recorded.

Results:

There were significant improvements of all functional outcomes (FAAM, SF-36, and VAS (p < 0.001 all)) with an average follow-up of 20.8 months. An average operative time was 30.2 minutes. Patients reported no previous pain after the operation (VAS 0/10, 54/62) and mild pain (VAS 1-2/10, 8/62). There were 6 patients with osteochondral injury intraoperatively and 9 patients with enlargement of anteroinferior tibiofibular ligament (AITFL). Recovery times included returned to ADL 4.9 weeks, to work 6.8 weeks, and to sports 5.8 months. Four patients had saphenous nerve irritation from the medial button and this was fully recovery at 4.8 months post-operatively and 2 patients has mild pain on fibular. There were no migration or disruption of suture button and no wound complications.

Conclusion:

Isolated sublte syndesmotic injury after ankle injury was successfully confirmed by anterior ankle arthroscopic examination and arthroscopic debridement and suture button fixation demonstrated significant improvement of functional outcomes as measured with FAAM, SF-36, and VAS. and patients were able to return previous activities. This technique is effective, safe, and feasible for treatment in patients with isolated subtle syndesmotic injury.
Minimally Invasive Versus Open Akin Osteotomy: A Comparative Study
Authors: Schilde Sebastian , Gutteck Natalia , Delank Karl-Stefan
Published: November 2020

Category:

Midfoot/Forefoot; Bunion

Introduction/Purpose:

Minimally invasive techniques of Akin osteotomy grow in popularity in order to minimize wound healing problems. To date it is recommended to keep the lateral corticalis intact during first phalanx osteotomy. The lack of direct visual control makes this a challenging goal in minimally invasive surgery. This retrospective study investigates whether or not the perforation of the lateral corticalis causes clinical or radiological negative effects. The quality of fixation with crossed K-wires and double threaded screws is compared.

Methods:

184 patients (210 feet) with symptomatic mild to severe hallux valgus deformity and pathological interphalangeal angle (IPA) of at least 10° underwent surgery combined with Akin osteotomy. 124 minimally invasive Akin osteotomies were fixed with two crossing K-wires and compared to 86 Akin osteotomies in open technique with double threaded screw fixation. After 6 and 12 weeks IPA and bony consolidation were assessed.

Results:

Preoperative interphalangeal angles were mean 13.4° (+- 3.6°) (minimally invasive group (MI)), or 13.3° (+- 3.5°) (open surgery group (OS)) degrees (p>0.05).Perforation of the lateral corticalis occurred in 12 (13.9%) (OS), or 64 (51.6%) cases (MI), respectively.12 weeks after surgery the mean IPA was 4.1° (+- 1.4°) (MI), or 4.8° (+- 1.2°) in the open surgery group (OS) (p > 0.05).Bony consolidation was noticed after 6 weeks (OS, double threaded screw) or 12 weeks (MI, crossing K-wires).Three deep infections occurred in the OS group after Lapidus arthrodesis and two deep infections were registered in the MI group after MICA. All patients required revision with removal of implants. Pseudarthrosis did not occur in any group.

Conclusion:

Perforation of the lateral corticalis did not cause negative effects on bone healing or IPA. Minimally invasive Akin osteotomy provides equivalent correction of IPA compared to open surgery with a slightly prolonged radiological bony consolidation. The fixation technique had no influence on IPA correction.
The Trans-Syndesmotic Axis in Relation to the Distal Anterior Medial Tibial Cortex
Authors: Schlatterer Daniel R. , Deal James , Krautmann Kurt M.
Published: November 2020

Category:

Ankle

Introduction/Purpose:

Gardner et al. (2006) reported that over 50% of operative syndesmoses are malreduced. The functional consequence of syndesmotic malreduction at two years was reported in 2012. Miller et al. in 2013, found that the 15° and 30°clamp positions caused fibula external rotation and over compression of the syndesmosis joint. The 0° medial clamp position which was in line with the trans-syndesmotic axis (TSA) did not negatively impact fibular reduction as did the other two posterior clamp positions. The purpose of this study is to identify the medial exit point of the TSA on the tibia. We hypothesized that the TSA on the medial side of the ankle would be a constant distance from the medial anterior tibial cortex.

Methods:

Fifty consecutive CT scans of uninjured ankles were reviewed from our image archive system. On an axial 2- dimensional reformatted image proximal to the ankle joint that included the entire incisura a line was drawn connecting the anterior and posterior limits of the incisura of the tibia. A second line was then drawn at 90 degrees at the midpoint of the first line and extended medially.

Results:

The average distance of the medial TSA exit point from the anterior edge of the distal medial tibia was 2.9 mm (Range 0- 9 mm, standard deviation 2.03 mm). The average anterior to posterior length of the medial distal tibia was 23.6 mm (Range 16-30, standard deviation 3.01 mm).

Conclusion:

Syndesmosis reduction clamp placement may first involve identifying the TSA based upon the anterior edge of the distal medial tibia. This region may be used to locate the TSA for optimal medial clamp placement. This study provides a foundation for future clamp placement investigations.
Trends in Sport Related Foot and Ankle Injuries in Adults 65 and Over Presenting to US Emergency Rooms from 2009-2018: A Descriptive Epidemiology Study
Authors: Scott Devon , Canton Stephen P. , Hogan MaCalus V. , LaBaze Dukens
Published: November 2020

Category:

Sports

Introduction/Purpose:

The percentage of the U.S population that is age 65 and older is expected to rise to 19.3% by the year 2030, up from 13% in 2010. Only 39% of seniors get the recommended amount of weekly exercise. This has led to Medicare sponsored fitness plans to increase of the number of older adults being active. For this percentage it is important that they are aware of safety precautions and ways to prevent injuries. One study showed that in elderly men still active in sports 75% of injuries were located in the lower extremity. The purpose of this study is to trend sports related foot and ankle (SFA) injuries in patients 65 and over that presented emergency departments from 2009 to 2018.

Methods:

Data was obtained from the National Electronic Injury Surveillance System (NEISS). Injury data is obtained daily from the emergency departments of approximately 100 hospitals across the United States and its territories. This serves as a probability sample of over 5000 hospitals across the country. Each case recorded is given a statistical weight based on the study design. CPSC analysis has the ability to make adjustments to more accurately represent the entire United States population. Hospitals are group in five strata mostly based on hospital size and number of ED visits they receive per year. The database was set with query inputs of patients aged 65 and over that presented with sports related injuries of the lower leg, ankle, foot and toes from 2009 - 2018.

Results:

An approximate total of 216,334 SFA injuries presented to emergency rooms in persons age 65 and over. Contusions/abrasions accounted for 11.7% of total injuries; lacerations (12.4%); fractures (20.9%); sprains and fractures (22.7%). Other types of injuries accounted for 32.3 %. There was an approximate total of 1,654,666 sports related injuries. Upper extremity had the highest percentage at 24.6%. Ages 65-69 accounted for 38.8 %. The trend for the SFA injuries increased 39.9% from 2009 to 2018, while the trend for overall sports injuries rose 83%. The percentage of SFA out of all sports injuries has decreased 23.6% from 14.81% of total sport injuries in 2009 to 11.32% in 2018.

Conclusion:

As the population ages, more seniors are remaining active and more are participating in sports. Thus, the increase in the number of sport related injuries. This increase however has outpaced the number of foot and ankle specific sport injuries. Over the time span of the study there has been an increase in percentage of hand, wrist and knee injuries. Further research is needed to delineated which specific sports and activities cause the most SFA injuries. This information can then be used to educate this population on injury prevention.
Safety and Outcomes of Early Fixation in Patients who Suffered an Ankle Fracture
Authors: Shah Ashish , Hawkins Jacob , Alexander Bradley , Agarwal Abhinav , Cage Benjamin B. , Greco Elise M. , Barranco Hannah M. , Patel Akshar
Published: November 2020

Category:

Ankle

Introduction/Purpose:

Ankle fractures are a common injury in the United States leading to increased ER visits and healthcare costs. Additionally, these injuries normally lead to prolonged immobilization that can make it difficult for patients to return to work and normal activities. By optimizing fracture healing and decreasing the amount of time to union patients can avoid the frustration of prolonged immobilization and return to daily activities more quickly. It is believed that early surgical fixation of ankle fractures can lead to wound complications while late fixation can lead to issues with reduction during surgical intervention. This study was undertaken to determine if there is a difference in wound complication and time to union between early and late fracture fixation.

Methods:

From July of 2008 to June of 2018, a retrospective chart review of 321 patients who underwent ankle fracture corrected with ORIF was performed at a single institution. Patients with pilon fractures, poly trauma, open fractures, or less than 3 months of follow up time were excluded from our study. After exclusion were made there was 232 patients remaining. All patients were then stratified by time to surgery after injury and injury classification. The cohorts were surgery within 2 days with 31 patients, surgery within 7 days with 69 patients, and patients that had surgery after 8 days (132). The patients were also stratified according to the Lauge-Hansen classification. The cohorts were PA, PER, SA, and SER.

Results:

The average time to union for patients who were operated on within 2 days of injury was 108.48 days, 106.52 days for patients operated on between 3-7 days, and 97.59 days for patients operated on after 7 days. Wound complications were highest in the cohort operated on within 2 days at 9.6%. Patients operated on between 3 and 7 days had the lowest rate of wound complications at 2.8%/. Patients with an SER Lauge-Hansen classification has the fastest time to union at 94.04 days and individuals with an SA had the longest at 139.30 days. Wound frequency for patients with a classification of PA had the highest wound complications at 20%.

Conclusion:

There has been little research done on how time to surgery affects wound complications and healing time in ankle fracture fixation. Patients that received surgery after 7 days achieved union the fastest. We saw that wound complication rate was greatest in the cohort that had surgery within 2 days of injury. Injury classification did factor into union time and wound complications. Overall, there was not a significant difference in wound complication between early fixation and delayed fixation. [Table: see text]
No Progression of Radiological Adjacent Joint Arthritis Noted in Patients with Type II DM undergoing Total Ankle Replacement: A 5 Year Follow Up Study
Authors: Shahid Zuhaib , Hutt Nicholas , Allport Jack , Ramaskandhan Jayasree Ramas , Refiae Ramsay , Siddique Malik S.
Published: November 2020

Category:

Ankle; Ankle Arthritis; Diabetes

Introduction/Purpose:

Total Ankle Arthroplasty [TAR] is a recognized treatment for end stage osteoarthritis. Many of these patients also have Type 2 Diabetes. There is a lack of literature of patients undergoing TAR surgery who belong to this cohort and any available literature has shown negative outcomes in such surgery. We aim to study whether the radiological outcomes of such patients undergoing TAR is different to their non diabetic counterparts performed at our Tertiary center.

Methods:

We conducted a retrospective study of patients undergoing Total Ankle Replacements between 2006 and 2014. Both patients with Type 2 Diabetes and non-diabetic patients were included. Type 1 Diabetics were excluded. Pre-operative screening of patients included thorough clinical assessment including swelling, warmth, erythema and neurovascular assessment including proprioception, vibration and neuro-filament testing. True AP, lateral X-Ray weight bearing views were obtained. MRI or CT scan was carried out on all patients pre-operatively. Patients were reviewed with X-Ray at 3, 6, and 12 month post operatively. Any radiolucency was defined as gap >2mm between the implant and the bone which was not seen at 3 month post op x-ray. Painful ankle replacement implants were investigated by SPECT CT scan.

Results:

9(3.9%) of the 230 patients were diabetic. Pre-operative radiographs revealed disease confined to OA, MRI and CT scans showed no evidence of bone debris, fragmentation of articular surfaces, translation of Talus or symptomatic OA in the Subtalar or Talo-navicular joint requiring treatment. Radiological analysis at 5 years demonstrated no evidence of loosening, implant subsidence, migration or periprosthetic cysts. No x-ray progression of arthritis was noted in the Subtalar, Talo-navicular or midfoot joints in Diabetic patient group. At the latest follow up, no radiological features of Charcot arthropathy was noted in the peri-prosthetic area.

Conclusion:

Our radiological outcome study has demonstrated that at minimum of 5 years, patients with diabetes who underwent TAR did not show any progression of arthritis in adjacent joints. Our study highlights that in the absence of diabetic neuropathy, it is safe to offer TAR in patients with Type II DM.
Outcomes following Subchondroplasty in the First Metatarsal Head
Authors: Sharma Akhil , Akoh Craig C. , Parekh Selene G.
Published: November 2020

Category:

Midfoot/Forefoot; Other

Introduction/Purpose:

Patients with subchondral bone marrow lesions often present with arthritic symptoms causing severe discomfort. Recently, subchondroplasty has been offered to treat such patients who suffer from symptoms of bone marrow edema. Calcium phosphate is percutaneously injected into these edematous regions to stabilize damaged bone and aid in healing. Subchondroplasty has been used successfully in the knee for femoral and tibial plateau injuries. However, its use in foot and ankle orthopaedics is relatively limited. This procedure has shown short-term success in patients with painful edema of the talus, as well as patients with early stage avascular necrosis (AVN) in the second MTP joint and the cuboid. Here, we report outcomes of two patients who developed AVN as a result of subchondroplasty in foot and ankle surgery.

Methods:

A retrospective review of patients was performed in those patients who underwent subchondroplasty in their first metatarsal heads between January 2017 and April 2017. Exclusion criteria included patients lost to follow up. Following implementation of inclusion and exclusion criteria, two patient charts were reviewed. Patients were treated by a single surgeon at the same institution. Data collected included patient demographics (age, laterality, BMI, ASA class, comorbidities), preoperative and postoperative VAS scores, FAOS scores, and imaging. Patients were followed up in clinic for two years following the procedure. Data was then analyzed via mean, standard deviation, median, and range for continuous variables and counts with percentages for categorical data.

Results:

In both patients, VAS scores increased, and physical exam showed greater tenderness over the affected region. The corresponding MRIs showed development of avascular necrosis in the region of the first metatarsal joint where the subchondroplasty had occurred. Both patients consequently had to undergo revascularization procedures and required further operations to correct the condition.

Conclusion:

Ultimately, subchondroplasty over the first metatarsal head failed in our patients. Exposure to calcium phosphate exacerbated their condition, resulting in symptomatic AVN. Although literature for subchondroplasty in foot and ankle orthopaedics is limited, preliminary results are unfavorable for use in the first metatarsal joint. Therefore, more long term data needs to be gathered this area before implementing the procedure more widely in foot and ankle surgeries.