bluuebunny/crossref_metadata_2025 huggingface dataset:
Weightbearing Computed Tomography for Assessment of Foot and Ankle Deformities: The Iowa Experience
Authors: Rojas Edward O. , Mansur Nacime S. , Dibbern Kevin N. , Auch Eli C. , Schmidt Eli , Vivtcharenko Victoria , Li Shuyuan , Phisitkul Phinit , Femino John E. , Netto Cesar de Cesar
Published: January 2022

Category:

Ankle; Ankle Arthritis; Other

Introduction/Purpose:

Weightbearing computed tomography (WBCT) is a reliable and precise modality for the measurement and analysis of bone position in the foot and ankle, as well as associated deformities. WBCT to assess three dimensional relationships among bones allowed the development of new measurements, as the Foot and Ankle Offset (FAO), which has high inter-rater and intra-rater reliability. This study reports our institution's experience utilizing WBCT for the care of foot and ankle patients by describing its utility across different orthopedic diseases in improving diagnostic assessment, aiding surgical planning, and expanding the use for objective clinical follow-up.

Methods:

The medical records of consecutive patients with various foot and ankle disorders that underwent WBCT examination as part of the standard of care at a single institution between November 2014 and August 2020 were retrospectively reviewed. Patient factors, including body mass index (BMI), sex, and patient comorbidities were collected. 3D coordinates for calculation of FAO were harvested using the Multiplanar Reconstruction (MPR) views were calculated from the obtained exams. Descriptive statistics were performed with Shapiro-Wilk test and the Anderson-Darling tests.

Results:

1175 feet and ankles (820 patients) had a WBCT performed over the studied 68 months. 53% of the subjects were male and 47% female. 588 of the acquisitions were from the right side (50.04%) and 587 from the left side (49.96%). Diabetes was present in 15.47% of, Rheumatic diagnoses in 4.52% and smoking habits in 44.10% of patients. Mean BMI of the sample was found to be 32.47 (32.03-32.90, 95% CI). The mean Foot and Ankle Offset (FAO) encountered in the study's population was 2.43 (2.05- 2.82, 95% CI; min -30.8, max 37.65; median 2.39).

Conclusion:

This study contains the largest cohort of WBCTs with accompanied FAO measurements to date, which can aid with establishing a new baseline FAO measurement for multiple pathological conditions. Acquiring WBCTs resulted in more specific diagnoses for patients with foot and ankle complaints. The ability to utilize WBCT for presurgical planning, its capability to provide a 3D reconstruction of patient anatomy, and use for assessment of advanced relational foot and ankle measurements, like FAO, demonstrate how WBCT may serve as a remarkable utility in clinical practice and has become a standard of care in our practice at the University of Iowa.
Syndesmotic Overload in 3-Component Total Ankle Replacement
Authors: Ruiz Roxa , Kvarda Peter , Susdorf Roman , Krähenbühl Nicola , Barg Alexej , Hintermann Beat
Published: January 2022

Category:

Ankle; Ankle Arthritis; Other

Introduction/Purpose:

Mobile-bearing total ankle replacement (TAR) potentially enables motion at the tibial implant- polyethylene insert (PI) interface. Such additional freedom of movement may overload periarticular ligaments and subsequently result in coronal translation of the talus. The aim of this study was to assess whether syndesmotic overload affects clinical and radiographic outcomes following mobile-bearing TAR and whether tibiofibular fusion is an effective treatment option.

Methods:

Thirty-one patients who underwent revision surgery for syndesmotic overload after mobile-bearing TAR were retrospectively analyzed. Clinical and radiographic outcome, including computed tomography scans, were assessed before and after index TAR, preoperatively to revision surgery, and at the last follow-up after revision surgery. Additionally, available computed tomography scans were analyzed.

Results:

Ankles with lateral talar translation prior to revision surgery were about 10 times more likely to have valgus tibial implant position (P =.003). A wide tibiofibular distance at the level of the syndesmosis after index TAR was associated with an increased hindfoot moment arm at revision surgery (P =.025). Decrease of PI height at revision surgery and a PI fracture were evident in 10 (32%) and 4 (13%) cases, respectively. Talar cyst formation at revision surgery was evident in 12 (39%) cases. Tibiofibular fusion was effective in restoring function of the replaced ankle and providing pain relief.

Conclusion:

Syndesmotic overload impaired clinical and radiographic outcomes after mobile-bearing TAR. Proper implant positioning and additional realignment procedures may prevent overload of periarticular soft tissue structures after mobile-bearing TAR.
Dynamic Portable Ultrasound Cutoff Values for Diagnosing Medial Ankle Instability in Supination External Rotation Ankle Injury: A Cadaveric Study
Authors: Saengsin Jirawat , Lubberts Bart , Sornsakrin Pongpanot , Soashkani Soheil , Waryasz Gregory R. , Guss Daniel , DiGiovanni Christopher W.
Published: January 2022

Category:

Ankle; Trauma

Introduction/Purpose:

In the setting of an isolated lateral malleolar fracture, stability is predicated by whether the deep deltoid ligament is intact. Portable ultrasound (P-US) has also been used in the clinical setting, allowing dynamic and non-invasive evaluation at the point of care. This study aimed to determine the cutoff values, as well as its sensitivity and specificity for diagnosing supination external rotation (SER) ankle injury stage IVb (with complete deltoid ligament rupture) using the P-US.

Methods:

Ten fresh-frozen cadaveric specimens were used. Medial ankle instability was assessed by the P-US. The assessment was performed with all structures intact and later with sequential transection of the AITFL, Weber-B fibular fracture, the PITFL, the superficial and deep deltoid ligament. In all scenarios, three loading conditions were considered, including the GST, the external rotation stress test (45N), and the simulated weight-bearing (750N). The P-US measurement of the MCS was assessed at the anteromedial aspect and inferomedial aspect of the ankle joint. The P-US measurement of the MCS was assessed by placing the ultrasound probe perpendicularly to the medial gutter at the anteromedial aspect and inferomedial aspect of the ankle joint. Three different MCS distances were measured, as demonstrated in Figure 1. To determine the sensitivity and specificity of the diagnosis of SER injury type IV using the P-US, a receiver operating characteristic (ROC) curve analysis was performed.

Results:

The MCS optimal cutoff point to distinguish SER ankle injury stage IVb from other injury stages ranged from 10.4 to 13.8 during the GST, 4.2 to 7.9mm during the weight-bearing stress, and 10.6-17.9mm during the external rotation stress test (Table 1). All P-US cutoff values provided acceptable sensitivity (60-100%), specificity (84-100%), and the area under ROC curve (0.8-1.0) for diagnosing SER ankle injury stage IVb.

Conclusion:

MCS cutoff points assessed with the P-US under the GST, weight-bearing, and the external rotation stress test demonstrate high sensitivity and specificity for detecting SER ankle injury stage IVb. The cutoff values vary depending on which loading condition is being used. Additional clinical studies are necessary in the in vivo setting to better understand the implications of these test conditions.
Location of the Ankle Osteochondral Lesion of the Talus (OLT) Corresponding to the Anatomical Axis of the Tibia (Loading Axis) Crosses the Ankle Joint
Authors: Sandberg Maxwell L. , Mirghasemi Seyed Alireza , Troiani Zachary , Vaupel Zachary M. , Fortin Paul T.
Published: January 2022

Category:

Ankle; Sports

Introduction/Purpose:

studies demonstrated that mechanical axis alignment affects the clinical outcome of the chondral repair surgery in the knee. Reduction in stress concentration around chondral defects with HTO has been found to favor cartilage repair in knee surgery. this study aimed to determine the relationship between the tibia mechanical axis alignment and OLT size and location.

Methods:

57 patients that underwent OLT repair between 2016-2020 were included. X-rays and MRIs of the ankle were used to collect data on OLT in the study group. X-ray measurements included (a)-measured as distance from where vertical line through center of tibia crosses to center the talar joint in AP view (medial, lateral), (b)- measured as distance from where vertical line through center of tibia crosses to the center talar body in lateral view (ant, post). The coverage angle, TLS, TAS, MA, TI, TTI angles were measured. MRI measurements included distance of the edge of the OLT lesion from the center of the talar surface, in three plans, and for location of the OLT lesion based on the 9-zone grid system.

Results:

37.3% of these patients had the mechanical axis of the joint cross posterolaterally, 15.6% anteromedially, 5.9% anterolaterally, and 3.9% posteromedially. 33.3% had the mechanical axis cross posteriorly along the midline of the lateral axis. Using the 9-zone grid to localize lesion location, lesions were most often seen in location 6 (37.3%), location 7 (21.6%), location 9 (21.6%), and location 4 (19.6%). Of note, 36.8% of patients with a posterolateral axis had lesions at location 6 and 26.3% at location 9. For patients with poster joint axis along the midline of the lateral axis, 47.1% had lesions at location 6 and 23.5% at location 7. There is a correlation between Lesion Surface Area and axis location in the AP view (Correlation coefficient: 0.301, P Value: 0.023). we found a significant difference for coverage angle (P<0.001), TLS (P<0.001), and TTI (P<0.001) for different groups.

Conclusion:

The significant correlation shows that the farther medial the location of the axis crosses the joint, the larger the surface area of the lesion. there is no significant difference between lesion length or area and location.
Open Ankle Fractures in the Elderly: Predisposing Factors and the Associated Mortality
Authors: Schermann Haggai , Ogawa Takahisa , Lubberts Bart , Waryasz Gregory R. , Kaiser Philip , DiGiovanni Christopher W. , Guss Daniel
Published: January 2022

Category:

Ankle; Trauma

Introduction/Purpose:

Previous studies raised awareness of high mortality associated with open ankle fractures in elderly patients. Mortality among this patient population has been reported about 23-27% during the first year postoperatively. The purpose of this study was 1) to investigate the association between patient factors and occurrence of open ankle fractures and 2) to quantify the risk of mortality associated with open ankle fractures.

Methods:

This is a retrospective cohort study of 1,045 patients 65 years and older, with ankle fractures, who were operated between 2010 and 2020. Background medical data included patient age, gender, language, race, fracture type and comorbidities. Case-control approach and logistic regression analysis were used to identify risk factors for open fractures. Propensity score matching and survival analysis were used to measure the hazard of mortality with ankle fractures.

Results:

There were 128 (12.2%) patients with open ankle fractures in this cohort. Patients with open ankle fractures higher odds of belonging to the age group of 70 to 79 years (OR=1.7, p=0.03) and 80 to 89 years (OR=1.8, p=0.04), having a diagnosis of hypertension (OR=2, p=0.006) and chronic kidney disease (OR=2.9, p=0.005), and smoking (OR=1.7, p=0.049). Open ankle fractures were associated with higher risk of mortality (HR=1.7, p=0.03). Other variables related to mortality in these patients were ischemic heart disease (HR=1.9, p=0.009), chronic kidney disease (HR=1.99, p=0.02), peripheral vascular disease (HR=1.8, p=0.03) and diabetes (HR=2.1, p=0.006).

Conclusion:

This study identifies older patients with comorbidities as having higher risk of open, compared to closed ankle fracture. Open ankle fractures are associated with higher mortality in this population, possibly indicating the need for control of comorbidities, reduction of fall risk and barrier protection as means of primary prevention.
Initial Experience with a Bioresorbable Polymer Anchor
Authors: Schiff Adam P. , Kumar Jayanth , Burnham Robert R. , Hamid Kamran S. , Pinzur Michael S.
Published: January 2022

Category:

Ankle; Ankle Arthritis

Introduction/Purpose:

Anchors are frequently used in reconstructive orthopedic surgery to achieve fixation of soft tissue to bone. Anchors vary with respect to material composition, configuration, and methods of fixation at the site of attachment. The fixation component of anchoring devices has generally evolved from metal-fabricated implants to various types of bioresorbable anchors. The SonicAnchorTM (Stryker, Kalamazoo, MI USA) polymer implant provides a unique form of anchor fixation using SonicFusionTM technology to achieve interdigitation within cancellous bone while being radiolucent and providing a small footprint.

Methods:

During a four-year period, 116 patients underwent a reconstructive orthopedic foot and ankle surgical procedure with the use of at least one bioresorbable polymer anchor (SonicAnchor implant). There were 59 males and 57 females, with an average age of 42 years (range: 12-83 years).

Results:

A total of 233 bioresorbable anchor (SonicAnchor) implants were used in 116 patients. Of the 116 patients, 108 (93.1%) achieved successful clinical healing of their surgery at their most recent follow-up. The average follow-up duration was 309 days (range: 14-1,429 days). Eight (6.9%) patients were lost to follow-up prior to clinical healing. Two (1.7%) patients underwent reoperation. Also, 65 (56%) patients had at least six months of follow-up and 36 (31%) had at least one year of follow-up.

Conclusion:

This preliminary clinical trial of patients undergoing soft tissue repair or reconstruction with a bioresorbable polymer appears to perform comparably to other commercially available devices. The lack of adverse events, mechanical failures, or infections further supports the safety of this device.
Risk of Injury to the LDCN and IACN During Surgical Approaches to the Foot and Ankle: an Anatomical Study using 3-Tesla Magnetic Resonance Imaging
Authors: Shah Vrajesh J. , Mitchell Brendon , Ghetti Claudio B. , Huang Brady K. , Kent William , Foran Ian M.
Published: January 2022

Category:

Ankle; Other

Introduction/Purpose:

The dorsomedial branch of the lateral dorsal cutaneous nerve (dmLDCN) and anastomotic branch to the intermediate dorsal cutaneous nerve (AICN) are at risk during foot and ankle surgery. Prior studies of the distal sural nerve on cadaveric specimens are limited by small sample size.1-7 We sought to use high-field 3-tesla (3T) magnetic resonance imaging (MRI) to examine a significantly larger cohort and obtain a more representative sample of the course of the dmLDCN and AICN. A more generalizable understanding of the course and position of these structures will aid surgeons intraoperatively in avoiding iatrogenic injury when performing the dorsomedial approach to the fifth metatarsal, as well as the sinus tarsi and extended sinus tarsi approaches for calcaneal fractures and subtalar/calcaneocuboid fusions.

Methods:

High-field 3T MRI studies performed between January 2015 to January 2020 were reviewed. Three blinded reviewers at a single academic center measured the coronal distances of dmLDCN and AICN from the fifth metatarsal styloid (5MS). Intraclass correlation coefficients (ICC) were calculated to assess reviewer reliability. We analyzed the upper and lower quartile ranges to evaluate the risk of iatrogenic nerve injury with standard surgical approaches.

Results:

A total of 125 foot and ankle 3T MRIs were measured. Intraclass correlation coefficient was excellent at 0.87 for dmLDCN to 5MS and 0.88 for AICN to 5MS. 1st and 4th quartile range for the dmLDCN to the 5MS was 0.5-0.7 cm and 0.9-1.4 cm, respectively. 1st and 4th quartile range for the AICN to the 5MS was 1.6-1.9 cm and 2.3-3.2 cm respectively. The AICN was identified in 47.2% of the images.

Conclusion:

The dmLDCN, AICN, and SN are vulnerable to iatrogenic injury during surgical approaches to the fifth metatarsal and calcaneus. Our 1st quartile range for the dmLDCN to the 5MS of 0.5-0.7 cm suggests that nearly 25% of our values measured by 3T MRI were lower than the reported range of 0.7-1.2 cm by Fansa, suggesting iatrogenic injury to the dmLDCN with the 'high and inside approach' to the fifth metatarsal may be higher than previously thought. The 4th quartile range of the AICN's distance from the 5MS of 2.3-3.2cm places it at risk with the sinus tarsi approach.
Comparison of Newly Designed Three Spike Insole and Total Contact Insole in Refractory Plantar Fasciitis: A Randomized, Double-Blinded, Non-Inferiority Study
Authors: Shim Dong Woo
Published: January 2022

Category:

Ankle; Hindfoot

Introduction/Purpose:

Plantar fasciitis is one of the common foot complaints that is chronic and can induce dysfunction. Total contact insole (TCI) is simple but effective in treating plantar fasciitis. Nevertheless of the effect, the cost and the long duration for production have been the major flaws. Therefore, we developed newly designed three-spike insole (TSI) that can be commercially productive and compared the clinical outcomes with TCI.

Methods:

Patients with plantar fasciitis refractory to conservative treatment for more than 6 weeks were candidates. We produced insoles with hardness of 58 +- 5 Shore-A. Twenty-eight patients were randomly allocated to use either TSI or TCI evenly (Figure 1). The following assessment tools were used: visual analog scale (VAS), American Orthopaedic Foot & Ankle Society score, Foot and Ankle Outcome Score, Karlsson-Peterson (KP) score, Short Form-36 for quality of life, and Foot Function Index. Non-inferiority was declared if VAS was within the statistical variability of minimal important difference. A blinded assessor evaluated the groups at baseline and after 6, 12, and 24 weeks.

Results:

The groups were homogenous for majority of variables at baseline. Overall patient-reported satisfaction showed improvement from mean 5.2 (range, 1 - 12) weeks of wearing and all clinical outcome scores showed significant improvements in both groups over time on the basis of Friedman test (p <.05). TSI showed non-inferiority to TCI at each time point. Post hoc analysis revealed that many scales showed significant superiority of TSI at 3 month (p <.0125) and KP score at 6 month (p <.001).

Conclusion:

We reaffirmed that semi-rigid insole is effective in refractory plantar fasciitis and showed TSI restores pedal function more rapidly than TCI. TSI can be not only effective in deriving better clinical outcomes but also be manufactured for popularization to lower the price and producing time of orthosis.
Posterior Hindfoot Endoscopy Using 1.9-mm Diameter Needle Arthroscopy: A Cadaveric Study
Authors: Shimozono Yoshiharu , Ito Yoshiharu , Ryoki Hayato , Sakai Sayako , Ishie Shinichiro , Arai Ryuzo , Kuroda Yutaka , Matsuda Shuichi
Published: January 2022

Category:

Ankle; Arthroscopy; Hindfoot; Sports

Introduction/Purpose:

Posterior hindfoot endoscopy is a safe and effective treatment for posterior ankle impingement syndrome (PAIS) and flexor hallucis longus (FHL) tendon disorders. As frequent coexistence of PAIS and FHL tenosynovitis has been reported, it is important to investigate FHL tendon pathology concomitantly when treating PAIS. However, the visualization of FHL tendon distal to the retinaculum is limited when using conventional rigid arthroscopy. Additionally, wound-healing problems following hindfoot endoscopy have been still reported. Recently, a novel 1.9-mm diameter needle-arthroscopic system has been introduced. Its small and semirigid features can help reduce the risk of wound complications and can make it easier to perform FHL tendoscopy. The purpose of this study was to assess whether 1.9-mm diameter needle-arthroscopy was useful for hindfoot endoscopy in a cadaveric model.

Methods:

A 1.9-mm diameter arthroscopic system (NanoScopeTM, Arthrex) was used to perform a hindfoot endoscopy in 6 human donor ankles (3 pairs). The arthroscope tube is 9.5-cm long and semi-rigid, and has a 1.9-mm outer diameter. The scope's direction of view is 0°, with a 120° field of view. Posteromedial and posterolateral portals were established. Visualization and operative reach with tailored arthroscopic instruments were recorded, including posterolateral talar process, posterior talofibular ligament, intermalleolar ligament, subtalar joint, ankle joint, and flexor hallucis longus (FHL) tendon. Finally, a conventional 4.0-mm diameter arthroscope with a 30° angle was used to compare the visualization of FHL tendon.

Results:

All significant structures were successfully visualized and reached in all specimens. In ankle joint, all of the tibial surface was visualized, but visualization of talar surface was limited. Due to its wide 120° field of view, there was no difficulty obtaining sufficient visualization in any structures. As this needle-arthroscopic system has the semirigid frame, FHL tendoscopy was easily performed via the posterolateral portal. In all specimens, the FHL tendon was visualized from the level of ankle joint to the Knot of Henry (Zone 1 and 2), and the flexor digitorum longus tendon crossing obliquely over the FHL tendon was observed (Figure). The conventional arthroscope could not be inserted into the tunnel underneath the sustentaculum tali in any specimens.

Conclusion:

Posterior hindfoot endoscopy using a 1.9-mm diameter needle-arthroscopy provides effective visualization and surgical reach of all significant structures for the treatment of PAIS. Its small and semirigid features also make the FHL tendoscopy less invasive and more accessible than conventional rigid arthroscope.
Quantification and Comparison of Talar Exposure Utilizing A Posteromedial Approach and Medial Malleolar Osteotomy
Authors: Shofoluwe Ademola I.
Published: January 2022

Category:

Ankle; Hindfoot; Trauma

Introduction/Purpose:

Fractures of the talus contain a variety of morphologies including the head, neck, body, dome, lateral process, posterior process, and medial/lateral tubercles. Specifically, the posterior medial approach is useful for surgical fixation of posterior process fractures. The use of the medial malleolar osteotomy is beneficial in more extensive medial and distal exposure for neck or neck/body fractures. The purpose of this study was to quantify the area of osseous exposure afforded by a posteromedial approach to the talus and medial malleolar osteotomy. We believe this can be potentially useful for preoperative planning. To the authors' knowledge, a quantitative comparison of the talar access afforded by these two distinct approaches has yet to be described in the literature.

Methods:

Five fresh frozen cadaveric lower extremities were dissected using a posteromedial approach and medial malleolar osteotomy respectively. Following exposure, the talar surfaces directedly visualized and demarcated along its boarders using a 2.0 mm drill bit orthogonal to the talar surface. The surface visualized was labeled and captured using a calibrated digital image. The digital images were then analyzed using ImageJ software (National Institutes of Health, Bethesda, MD) to calculate the surface area of the exposure.

Results:

The average square area of talus exposed using the posteromedial approach was 9.70 (SD = 2.20, range 7.20 - 12.46) cm2. The average quantity of talar exposure expressed as a percentage was 9% (SD = 1.58, range 7.03 - 10.40). The average square area of talus exposed using a medial malleolar osteotomy was 14.32 (SD 2.00, range 11.26 - 16.66) cm2. The average quantity of talar exposure expressed as a percentage was 12.94% (SD = 1.79, range 9.97 - 14.73). The posteromedial approach provided superior visualization of the posterior talus, while the medial malleolar osteotomy offered greater access to the medial body.

Conclusion:

The posteromedial approach and medial malleolar osteotomy allow for significant exposure of the talus, yielding 9.70 cm2 and 14.32 cm2, respectively. Given the differing portions of the talus exposed, surgeons may prefer to utilize the posteromedial approach for surgical fixation of posterior process fractures and elect to use a medial malleolar osteotomy in cases requiring more extensive medial and distal exposure for neck or neck/body fractures.
Efficacy of Fluoroscopically Guided Corticosteroid Injections for Foot and Ankle Pain
Authors: Slone Tyler , Ciesa Michael , Bartholomew Ania , Cheney Nicholas A , Clark Brian C.
Published: January 2022

Category:

Midfoot/Forefoot; Ankle; Ankle Arthritis; Hindfoot; Lesser Toes

Introduction/Purpose:

Arthritis of the foot and ankle can severely hamper quality of life resulting in decreased mobility and functionality. Conservative treatment can involve corticosteroid injections into affected joint spaces. Fluoroscopic guided injections provide confirmation that the injection was successfully applied within the appropriate joint space. Due to this, they can be of diagnostic value and result in more accurate injection placement. Current literature focuses on ultrasound guided injections and does not fully address the efficacy of fluoroscopic injections. Objective: Assess and determine overall efficacy of fluoroscopically guided corticosteroid injections including the degree and period of relief provided.

Methods:

We retrospectively reviewed patient charts from 2016 through 2020 of patients that received fluoroscopically guided corticosteroid injections in foot or ankle joints. 224 injections were reviewed, gathering responses to percent relief, days of relief, pre-/post-injection VAS pain score and efficacy of repeat injections. Additionally, Kellgren-Lawrence arthritis scale vs pain relief were analyzed.

Results:

Analysis limited by incomplete patient response. 24/83 (28.9%) injections provided less than 2 weeks of relief while 59/83 (71.1%) injections averaged 109.49 +- 72.03 days of pain relief. Of 127 responses, post-injection relief at first follow up had an average VAS reduction of 2.87 +- 3.17 with 70.38 +- 30.8 % improvement. 40 subjects with repeat injections had 109.41 +- 64.96 days of relief per injection. No significant correlation was found between joint injected or degree of arthritis and percent improvement.

Conclusion:

Fluoroscopic guided injections are an effective conservative option providing prolonged but varying relief of 3-4 months irrespective of the specific joint or degree of arthritis. Repeat injections show similar efficacy. In contrast to ultrasound guided injections, fluoroscopy provides additional diagnostic and therapeutic value. This can be beneficial if the injections fail and the patient must progress to surgery. Future prospective studies could directly compare different injections modalities and further analyze efficacy for specific diagnoses.
Percutaneous Correction Surgery of Hammer Toes with Biodegradable Pins
Authors: Sotelano Pablo , Villena Daniel S. , Parise Ana C. , Conti Leonardo A. , Carrasco Nelly M. , Verbner Jonathan M. , Araujo Maria Gala Santini
Published: January 2022

Category:

Lesser Toes; Midfoot/Forefoot

Introduction/Purpose:

The standard treatment for deformities in lesser toes is proximal interphalangeal arthrodesis with Kirschner wires. It is relatively inexpensive but complications have been described such as infection, recurrences and misalignment. New devices were developed, among them biodegradable pins avoid the need for withdrawal and exposure to the outside. The objective of this study was to describe the clinical and radiological results one year after surgery in a group of patients with a diagnosis of rigid hammer toes, who underwent percutaneous surgical correction with a biodegradable pin.

Methods:

Methods: We present a retrospective study in a consecutive series of cases with a diagnosis of hammer toe operated between January 2016 and December 2018. Patients older than 18 years of age who underwent a percutaneous proximal interphalangeal arthrodesis, with a biodegradable pin, were included. The patients were asked through a survey to rate the results obtained with the intervention (excellent, very good, good, fair and bad). loss of contact with the ground was evaluated with podobarography. The patients were evaluated with weightbearing X rays to assess interphalangeal alignment and consolidation. We used the AOFAS scale to assess clinical results, preoperatively and one year after surgery. Postoperative complications, infection, wound dehiscence, rupture of osteosynthesis material, loss of correction were also evaluated.

Results:

117 patients were identified, 23 (16%) underwent bilateral surgery (140 feet), with a total of 220 lesser toes who underwent proximal interphalangeal arthrodesis stabilized with percutaneously biodegradable pin. 50% had a minimum follow-up of 1 year. The pre-surgical AOFAS of 52 improved to 95 points in the postoperative period. In 96 (43.63%) fingers, an F1 base osteotomy was performed to correct the alignment in the coronal plane. We observed pseudo osteoarthritis in 5% of the toes but with good alignment. We observed 6% of floating fingers, the pin was removed in 5 fingers; without loss of correction. In 1.36% cases it migrated early, causing a recurrence of the lesion. Patient satisfaction was excellent or very good in 79 %.

Conclusion:

According to our serie results, we consider that percutaneous technique with biodegradable pins manages to maintain adequate alignment and a consolidation rate both in radiological and clinical results with good patient satisfaction. No infection case was reported. We found a low rate of biodegradable pin removal. For its part, the biodegradable plug allows osteotomies to be performed with the implant already in place, it does not require routine removal of the implant, reducing the need for a second intervention.
Preoperative Depression is Associated with Increased Complications Following Ankle Fracture Surgery
Authors: Tahmid Syed , Broggi Matthew S. , Hurt John , Kadakia Rishin J. , Bariteau Jason T. , Coleman Michelle M.
Published: January 2022

Category:

Ankle; Trauma

Introduction/Purpose:

Ankle fractures are a common injury treated by orthopaedic surgeons with a rising incidence. Preoperative depression is a known risk factor for postoperative complications in joint replacement surgery, however its effects on outcomes following ankle fracture surgery is unknown. The purpose of this study was to investigate the relationship between preoperative depression and outcomes following ankle fracture surgery.

Methods:

In this retrospective study, the Truven MarketScan claims database was used to identify patients who underwent outpatient ankle fracture surgery from January 2009 to December 2018 using Common Procedure Terminology (CPT) codes. Patient characteristics, and medical comorbidities were collected. Patients with and without a diagnosis of preoperative depression were identified based on International Classification of Diseases (ICD) codes. Chi-squared and multivariate analyses were performed to investigate the association between preoperative depression and common postoperative complications following ankle fracture surgery.

Results:

In total, 107,897 patients were identified for analysis, 13,981 of whom were diagnosed with depression (13%). Preoperative depression was associated with the increased odds for postoperative infection (OR 1.33, CI 1.20-1.46), wound complications (OR 1.13, CI 1.00-1.28), pain-related postoperative emergency department visits (OR 1.58, CI 1.30-19.1), 30-day and 90-day readmissions (OR 1.08, CI 1.03-1.21 and OR 1.13, CI 1.07-1.18), sepsis (OR 1.39, CI 1.12-1.72) and postoperative development of complex regional pain syndrome (OR 1.46, CI 1.18-1.81).

Conclusion:

Preoperative depression in patients undergoing ankle fracture surgery is common and associated with increased complications following surgery. An understanding of patients' preoperative depression diagnosis can allow providers to modify perioperative and postoperative protocols for these higher risk patients. Further studies are warranted to investigate the degree to which depression is a modifiable risk factor.
Quantitative Evaluation of Ankle Instability Using a Capacitance-Type Strain Sensor
Authors: Teramoto Atsushi , Murahashi Yasutaka , Shoji Hiroaki , Kamiya Tomoaki , Watanabe Kota , Yamashita Toshihiko
Published: January 2022

Category:

Basic Sciences/Biologics; Ankle; Sports

Introduction/Purpose:

Manual evaluation is an important method for assessing ankle instability, but it is not quantitative. Capacitance-type sensors can be used to measure the distance on the basis of the capacitance value. We applied the sensor to the noninvasive device for measuring ankle instability and showed its utility.

Methods:

First, five ankles embalmed by Thiel's method were used in an experiment using a cadaver. The capacitance-type sensor was fixed alongside the anterior talofibular ligament (ATFL) of a specially made brace, and the anterior drawer test was performed. The test had been performed for the intact ankle, with the ATFL transected, and with both the ATFL and calcaneofibular ligament (CFL) transected. The anterior drawer distance was calculated by the sensor. Intra and interinvestigator reliability were also analyzed. Next, as a clinical study, a brace with a sensor was fitted to 22 ankles of 20 patients with a history of ankle sprain. An anterior drawer test at a load of 150 N was conducted using a Telos stress device. The anterior drawer distances measured by the sensor and based on X-ray images were then compared.

Results:

The mean anterior drawer distance for the intact cadavers was 3.7 +- 1.0 mm, 6.1 +- 1.6 mm with the ATFL transected (P < 0.001), and 7.9 +- 1.8 mm with the ATFL and CFL transected (P < 0.001). The intrainvestigator intraclass correlation coefficients (ICC) were 0.862-0.939, and the interinvestigator ICC was 0.815. In the experiments on patients, the mean anterior drawer distance measured by the sensor was 2.9 +- 0.9 mm and 2.7 +- 0.9 mm from the X-ray images. The correlation coefficient between the sensor and the X-ray images was 0.843.

Conclusion:

We carried out a quantitative evaluation of anterior drawer laxity using a capacitance-type sensor and found it had high reproducibility. It was also very strongly correlated with stress radiography measurements in patients with ankle instability. Capacitance-type sensors can be used for the safe, simple, and accurate evaluation of ankle instability.
Lateral Extensile Approach to the Calcaneus is Safe after Sinus Tarsi Incision: A Report of Two Cases
Authors: Udawatta Thiran , Goodnough Lawrence H. , Benirschke Stephen K.
Published: January 2022

Category:

Trauma; Hindfoot

Introduction/Purpose:

While the optimal surgical approach for operative treatment of calcaneus fractures is controversial. Regardless of index approach, post-injury sequelae such as malunion may require subsequent extensile exposures for reconstruction. In the tenuous soft tissues overlying the Whether a lateral extensile approach is safe following a previous sinus tarsi exposure has yet to be demonstrated.

Methods:

In this case report, two individuals underwent an initial sinus tarsi approach for reduction and fixation of calcaneus fractures, but went on to malunion or subtalar arthritis. A 'sham' surgery consisting of skin incision and initial flap elevation was performed to evaluate the efficacy of a lateral extensile approach to the calcaneus after previous sinus tarsi incision.

Results:

In each instance, the patients experienced uneventful skin incision healing, and subsequently had successful reconstruction with distraction subtalar arthrodesis via lateral extensile exposures.

Conclusion:

The lateral extensile approach to the calcaneus may be safely performed following sinus tarsi exposure.
Comparison of a Simple Anatomic Landmark-Based Achilles Tendon Measurement with Ultrasound and MRI Measurements
Authors: Urness Daniel , Thompson Austin R. , Sodders Emelia , Ensrud Erik , Meeker James E.
Published: January 2022

Category:

Ankle; Trauma

Introduction/Purpose:

Achilles tendon ruptures (ATRs) occurred with an incidence of 2.5 per 100,000 person-years in 2016. This rate has been increasing over the last decade and it has been postulated that this is due to the increasing activity level of an aging population. With a high and increasing incidence of this significant injury, further investigation must be done to optimize the treatment of ATRs. The degree of tendon lengthening has been correlated with clinical outcomes, with greater elongation being associated with worse outcomes. MRI and ultrasound (US) techniques have been validated in Achilles tendon measurements. We sought to develop a reliable, reproducible, and accurate measurement technique utilizing the manual palpation of anatomic landmarks that will be cost effective as well as convenient to perform, particularly intraoperatively.

Methods:

Both lower legs of 10 healthy subjects without history of Achilles tendon injury were examined. For US and anatomic landmark-based (ALB) measurements, subjects' ankles were held at 90o with the lateral aspect of the lower leg resting on the exam table. The length from the medial head of the gastrocnemius to the bottom of the non-compressed heal pad was measured by three raters using the US and ALB techniques. Two of those raters repeated the measurements one week later. MRI studies were obtained with ankles held at 90o. Using imaging software, the above measurements were made in sagittal and coronal series. A repeated measures mixed model method was utilized to model the measurement type and the length of the Achilles tendon. The length of the Achilles tendon measured by each measurement type was estimated with least square means. All pairwise comparisons were considered.

Results:

The Achilles tendon length was similar on the left [23.4 cm (95% CL: 22.3 cm, 24.5 cm)] and right [23.5 cm (95% CL: 22.4 cm, 24.6 cm)] legs. The average Achilles tendon length measured with the ALB technique was 23.2 cm (95% CL: 21.9 cm, 24.6 cm). The average Achilles tendon length measured with the US technique was 22.4 cm (95% CL: 21.0, 23.8). The average Achilles tendon length measured on the sagittal view of MRI was 24.1 cm (95% CL: 22.7, 25.4). The average Achilles tendon length measured on the coronal view of MRI was 24.2 cm (95% CL: 22.8, 25.5). Pairwise comparisons of the measurement types were not significantly different from 0.

Conclusion:

The ALB measurements were not statistically different from MRI or US. With orthopaedic surgeons in need of simple, noninvasive, and cost-effective methods to assess tendon length, the authors propose this ALB technique or US as valid ways to monitor that variable both during and after repair. These results set the stage for further evaluation of this measurement technique in the operating room in subjects undergoing ATR repair.
Valgus Drift after Total Ankle Arthroplasty
Authors: Vier David , Hamid Rasikh N. , Odum Susan M. , Jones Carroll P. , Cohen Bruce E. , Irwin Todd A. , Davis W. Hodges.
Published: January 2022

Category:

Ankle; Ankle Arthritis

Introduction/Purpose:

Total ankle arthroplasty (TAA) is a common treatment for ankle arthritis, but many challenges exist when attempting to correct and balance coronal plane deformity. Varus ankle arthritis tends to be stiffer and often leads to a more stable TAA, but valgus ankle arthritis tends to have more laxity especially in the setting of a progressive collapsing foot deformity. Failure to achieve appropriate deformity correction and soft tissue balance can result in recurrence of the deformity with valgus drift. The purpose of this study was to evaluate the longitudinal coronal plane alignment as well as outcomes in patients treated with TAA with resultant valgus drift.

Methods:

98 patients who underwent TAA for valgus ankle arthritis were identified through a prospectively collected database. All patients had a minimum of 2 year follow-up. The tibiotalar angle was measured on preoperative radiographs to include patients with valgus ankle arthritis five degrees or greater. Radiographic alignment in the postoperative period was compared to the alignment at final follow-up. Complications, failures, revisions, and reoperations were recorded. Patients were categorized by severity of preoperative valgus deformity into 3 groups: 5-10 degrees, 11-20 degrees, and greater than 20 degrees. Valgus drift was defined as greater than 5 degrees of valgus shift at final follow-up when compared to the postoperative alignment. Median follow- up was 49.2 (37.2-68.3 inner quartile) months.

Results:

Patients with greater than 20 degrees of preoperative valgus deformity had an initial postoperative alignment of 2 degrees of valgus and ended with an average of 5.5 degrees of valgus at final follow-up. The groups of patients with 5-10 degrees as well as 11-20 degrees of valgus were corrected to neutral (0 degrees) in the initial post-op period and ended with a final postoperative valgus alignment of 2.5 degrees and 2 degrees, respectively. Overall, 16 patients (18%) had greater than 5 degrees of valgus drift after their surgery, of which 2 failed and were revised (13%) and 5 had reoperations (31%).

Conclusion:

All groups of preoperative valgus deformity severity had some valgus shift overall at final follow-up. The most severe preoperative valgus deformities were least likely to be corrected to neutral with the index procedure and also on average drifted back to over 5 degrees of valgus. Patients with valgus drift after TAA can still have a good result but should be monitored closely. Overall, they did not have a high failure rate. This study emphasizes the necessity of correcting both the ankle and foot deformity when performing TAA for valgus ankle arthritis in order to maintain deformity correction.
Traumatic Peroneal Nerve Injuries: A Systematic Review
Authors: Vopat Bryan G. , Mackay Matthew , Ayres Jack M. , Harmon Ian , Tarakemeh Armin , Brubacher Jacob
Published: January 2022

Category:

Trauma

Introduction/Purpose:

The common peroneal nerve (CPN) is the most commonly injured peripheral nerve of the lower extremity in trauma patients. Traumatic CPN injuries have historically been associated with relatively poor outcomes and patient satisfaction, though recent outcome data appear promising. Given the variety of underlying injury modalities, treatment options, and prognostic variables, this study sought to evaluate and summarize current literature on traumatic CPN injuries and provide recommendations for treatment and future research.

Methods:

A systematic review was performed using PubMed, Embase and Cochrane databases per PRISMA guidelines. Search terms consisted of variations of 'peroneal nerve' and 'fibular nerve' combined with 'injury,' or 'laceration,' or 'entrapment,' or 'repair,' or 'neurolysis.' Information regarding treatment modality, outcomes and patient demographics were recorded and analyzed.

Results:

2,301 articles were identified in the initial search, 42 met eligibility criteria (Figure 1). Factors associated with better clinical outcomes included shorter pre-operative interval, shorter graft length when an interposed graft was used, nerve continuity and younger patient age. Sex or gender did not affect outcomes in any studies in this review. Motor grades of M3 or greater on the MRC scale are typically considered successful outcomes. In studies we analyzed, this was achieved in 81.2% of patients who underwent neurolysis, 78.8% of patients who underwent end to end suture, 49.8% of patients who underwent nerve grafting, 62.9% of patients who underwent nerve transfer, 86.0% of patients who underwent posterior tibial tendon transfer (PTTT) and 73.9% of patients who underwent surgery with concurrent PTTT.

Conclusion:

Included studies were heterogenous, complicating our ability to further analyze the data. It is not possible to uniformly advocate for the best treatment option given diverse injury modalities, presentations and prognostic factors. Many studies do not report outcomes with respect to specific injury modality. Future studies should clearly report outcomes based on injury modality and surgical treatment option. This would allow for greater analysis on the most appropriate treatment option for a given mechanism of injury. Newer surgical techniques, such as addition of growth factors to nerve repairs and concurrent tendon transfer are promising and should be further explored.
Importance of Midfoot Ligaments in a Hallux Valgus Cadaveric Model
Authors: Wagner Emilio , Wagner Pablo , Pacheco Florencia , López Mario , Palma Felipe H. , Guzman- Venegas Rodrigo
Published: January 2022

Category:

Bunion

Introduction/Purpose:

Hallux valgus (HV) is of uncertain origin. Even though a huge amount of treatment options are available, no clear cause for this deformity exist. To be able to further understand this frequent pathology, a cadaveric model should be developed. A cadaveric model was developed trying to obtain similar deformities to the ones observed in Hallux valgus (first ray varus and pronation). The objective of this research is to recreate some characteristics of a HV deformity, through sequential ligaments sectioning.

Methods:

8 fresh frozen lower leg specimens were used. Markers were attached to the medial and middle foot ray bones, including talus. A constant tibial axial load of 25 kg was used. Cyclic tibial rotation (to simulate gait phases) and 5 kg pull on the extensor and flexor hallucis tendons (EHL and FHL) were applied to the specimen. Limited and sequential medial and middle column ligamentous sectioning were performed, including the, dorsal and interosseous naviculo-cuneiform, intercuneiform, metatarso-cuneiform and intermetatarsal ligaments. After each ligament damage, bony alignment was measured including frontal (bone divergence) and axial plane (bone rotation).

Results:

After intercuneiform, Lisfranc and naviculo-cuneiform ligaments sectioning, a significant angular increase was found in the naviculo-cuneiform, intercuneiform and naviculo-metatarsal angles (p=0.001). Specifically, for bone rotation, the biggest change was found for the intercuneiform and naviculo-cuneiform angles. Regarding bone divergence, the biggest increase was found in the talo-metatarsal angle. No additional angular change was found after adding metatarso-cuneiform ligament damage. No change in the sagittal alignment was found.

Conclusion:

This model was able to recreate some parameters of the hallux valgus deformity. No flatfoot deformity was produced. Surprisingly, no significant angular change was produced after metatarso-cuneiform ligament damage. Most significant changes were found after intercuneiform and naviculocuneiform damage. Our findings suggest that midfoot instability has to be present to recreate a hallux valgus deformity.