bluuebunny/crossref_metadata_2025 huggingface dataset:
Normal Variation and Instability Values of the Tibiofibular Joint on Weightbearing CT
Authors: Hagemeijer Noortje , Chang Song Ho , Elghazy Mohamed Abdelaziz , Waryasz Gregory , Guss Daniel , DiGiovanni Christopher
Published: October 2019

Category:

Ankle

Introduction/Purpose:

Prompt management of syndesmotic instability is critical for optimizing clinical outcome, but subtle injuries may be difficult to diagnose. Application of modern imaging modalities such as weight bearing CT (WBCT) may better identify such injuries by virtue of assessing the distal tibiofibular articulation under physiologic load. The aim of this study was to evaluate the distal tibiofibular articulation using WBCT among patients with known syndesmotic instability and compare these findings with their uninjured contralateral sides, and thereafter corroborate such measurement differences with patients devoid of any syndesmotic injury.

Methods:

Patients with unilateral syndesmotic instability requiring surgical fixation (n=12) underwent bilateral ankle WBCT that incorporated the entire foot. A separate cohort of patients without ankle injury also underwent bilateral ankle WBCT for assessment of either a Lisfranc injury or forefoot condition (n=24). All WBCT imaging was performed preoperatively. A set of five axial plane tibiofibular joint measurements including one angular measurement were standardly assessed one cm above the tibial plafond. Values were recorded by two independent observers to assess for interobserver reliability scores. Interpretation of the intraclass correlation coefficients was carried out according to the guidelines proposed by Shrout: 0.00-0.10 virtually none, 0.11-0.40 slight, 0.41-0.60 fair, 0.61-0.80 moderate, 0.81 -1.00 substantial.

Results:

Among the control population without ankle injury, no differences were found between bilateral measurements (p-value range 0.172 - 0.961). Among those with known unilateral syndesmotic instability, values differed between the injured and uninjured side in five of six measurements— including syndesmotic area, direct anterior-, middle-, and posterior- difference, and sagittal translation (p <0.001, <0.001, <0.001, <0.001, 0.039, respectively). Those same measurements also differed when comparing the left-right delta values between uninjured and injured patients (p <0.001, 0.002, <0.001, <0.001, and 0.042, respectively). Fibular rotation differed neither in direct nor delta comparisons (p=0.460 and 0.271 respectively). Substantial agreement was found for all measurements except for sagittal translation, which had only slight agreement.

Conclusion:

This study highlights the ability of WBCT to effectively differentiate syndesmotic diastasis and fibular translation among patients with surgically-confirmed syndesmotic instability as compared to those without syndesmotic instability. It also underscores the importance of using the contralateral, uninjured side as a valid internal control. Additional studies are necessary to better understand the role of WBCT in prospectively diagnosing more subtle cases of syndesmotic instability among patients for whom the diagnosis remains in question.
Arthroscopy in Lateral Ankle Ligament Stabilization Surgery: Costs, Complications, Intra-Articular Defect Diagnosis, and Reoperations
Authors: Heenan G. Matthew , Parikh Kisan , Tarakemeh Armin , Schroeppel J. Paul , Mullen Scott , Vopat Bryan G.
Published: October 2019

Category:

Ankle, Arthroscopy

Introduction/Purpose:

Lateral ankle ligament stabilization may be performed with concomitant arthroscopy. Arthroscopy has been shown to aid in the diagnosis of intra-articular defects that often accompany lateral ankle ligament injuries. This study compares the differences in cost, complications, newly diagnosed intra-articular defects, and reoperations among patients with ankle sprain/chronic instability who underwent lateral ankle ligament repair/reconstruction with or without concomitant arthroscopic procedures.

Methods:

Data was collected from the PearlDiver Technologies Humana dataset using CPT and ICD9/10 codes. Patients included in this study (n=2,428) had records of ankle sprain or ankle instability prior to or on the same day as one of two procedures: lateral ankle ligament repair (n=1,236) or lateral ankle ligament reconstruction (n=1,211). This population was subdivided by whether patients had records of arthroscopic procedure(s) on the same day as the ligament surgery. This yielded four groups: repair with arthroscopy (n=314), repair without arthroscopy (n=922), reconstruction with arthroscopy (n=473), reconstruction without arthroscopy (n=738). Cost, complications, newly diagnosed intra-articular defects, and reoperations were assessed.

Results:

Cost was higher for arthroscopy groups: repair with arthroscopy ($5,991.32) versus repair without arthroscopy ($3,677.11; p<0.001); reconstruction with arthroscopy ($5,744.83) versus reconstruction without arthroscopy ($4,601.13; p=0.001). Proportionately more patients had complications in the repair without arthroscopy group than in the repair with arthroscopy group (9.87%, 5.41%; p=0.013). Proportionately more patients had newly-diagnosed intra-articular defects in arthroscopy groups: repair with arthroscopy (57.0%) versus repair without arthroscopy (35.6%; p<0.001); reconstruction with arthroscopy (63.0%) versus reconstruction without arthroscopy (39.8%; p<0.001). Proportionately more patients underwent reoperation for intra-articular defects in the combined arthroscopy group (6.89%) than in the combined non-arthroscopy group (4.18%; p=0.006). The average time until reoperation for intra-articular defects was shorter in the combined arthroscopy group (302.536 days) than in the combined non-arthroscopy group (473.886 days; p=0.045).

Conclusion:

Concomitant arthroscopy with lateral ankle ligament surgery is more expensive but does not appear to increase the overall complication rate and may allow surgeons to diagnose and treat more intra-articular pathology. Among patients requiring reoperation for intra-articular defects, the average time to reoperation was over 5 months shorter for patients receiving arthroscopy than for patients who did not receive arthroscopy.
Treatment Options for Osteoarthritis of the Ankle: Appropriate Distinction Between Brace Treatment and Arthrodesis
Authors: Hirano Takaaki , Akiyama Yui , Karube Tomoko , Haraguchi Naoki , Niki Hisateru , Mitsui Hiroyuki
Published: October 2019

Category:

Ankle Arthritis

Introduction/Purpose:

Ankle arthrodesis (fusion) for the treatment of osteoarthritis of the ankle (OA) was reported to have good therapeutic results; however, this has not been compared with conservative treatment. At this conference last year, brace treatment using an ankle-foot orthosis, Hiflex Foot Gear (HFG), was also reported to have good therapeutic results, which allows for slight mobility in the ankle joint while providing appropriate level of support for the ankle joint. On this occasion, the therapeutic results of brace treatment and fusion were compared, and treatment options for OA were examined.

Methods:

Subjects included nine cases and ten feet in a group that was diagnosed with stage IIIb OA or worse according to the Takakura Classification and were treated with HFG (mean age of 70.6 years, mean course observation period of 8.4 months) and nine cases and ten feet in a group that was treated with fusion for the same diagnosis (mean age of 58.1 years, mean course observation period of 25.5 months). The pre-treatment and post-treatment physician-initiated objective evaluation by the Japanese Society for Surgery of the Foot scale (JSSF scale) and patient-reported subjective evaluation by the Japanese Orthopaedic Association/ the Japanese Society for Surgery of the Foot, and subscales of Self-Administered Foot Evaluation Questionnaire (SAFE-Q) were examined, and improvements in each score in two groups were compared (post-treatment vs pre-treatment) by an unpaired t-test. The validity and reliability of JSSF scale and SAFE-Q have been established by psychometric verification

Results:

The improvement after the treatment for the HFG group and the fusion group was observed. JSSF scores were 16.1 (p < 0.001) and 35.5 (p < 0.001), respectively, and pain and pain-related scores in the SAFE-Q were 20.8 (p = 0.021) and 35.4 (p < 0.001), respectively. Physical function and daily living were 12.8 (p < 0.001) and 18.6 (p = 0.007), respectively, while social functioning scores were 18.0 (p = 0.001) and 32.8 (p = 0.001), respectively. The JSSF score for both groups was significantly improved. In SAFE-Q, physical function and daily living improved significantly in the HFG group, while pain and pain-related improved significantly in the fusion group.
Outcomes of Bridge Plating Versus Standard Fixation in Geriatric Ankle Fractures
Authors: Holzgrefe Russell E , Erwood Amalie , Maidman Samuel , Runge William , Gottschalk Michael , Bariteau Jason
Published: October 2019

Category:

Ankle, Trauma

Introduction/Purpose:

Ankle fractures represent one of the most common injuries encountered by foot and ankle specialists. Internal fixation of the lateral malleolus can be achieved by several different techniques, most commonly by lag screw and neutralization plating. However, ankle fractures in older patients often present technical challenges as osteoporotic bone is more commonly encountered which may require bridge plating techniques. This study compares outcomes in patients over age 50 years who underwent ORIF of the lateral malleolus with either a bridge plate or lag screw and neutralization plate technique.

Methods:

This retrospective study evaluated 56 patients with closed ankle fractures, aged over 50 years who underwent open reduction internal fixation of the lateral malleolus. These were divided into two groups: 36 patients had fixation with one or more lag screws and a neutralization plate, and 20 patients had fixation with a bridge plate technique. Fractures were stabilized with lag screw fixation when feasible, while bridge plating was utilized in patients where lag screw fixation was not possible. SF-36 scores were attained at a minimum one-year post-op. Final radiographs and complications were recorded.

Results:

The lag group had a mean age of 63 years, 17% men, 61% with syndesmotic screw fixation, and 56% with medial malleolus fixation. The bridge group had a mean age of 65 years, 15% men, 60% with syndesmotic screw fixation, and 70% with medial malleolus fixation. At minimum one-year, SF-36 physical component summary score was 74.2 ± 19.4 in the lag group vs 63.2 ± 24.8 in the bridge plate group (p=0.049). The SF-36 mental component summary score was 89.2 ± 12 in the lag group vs 75.5 ± 22.7 in the bridge plate group (p=0.009). One patient in each group required return to the OR for irrigation and debridement for infection. No patients experienced fixation failure and all fractures demonstrated union on final radiograph.

Conclusion:

In the present study of patients over age 50 years who underwent ORIF of an ankle fracture, as compared with bridge plating, lag screw and neutralization plating is associated with superior one-year SF-36 physical and mental summary scores with similar rates of complications. However, additional research is needed to determine to what degree this difference is causative or correlative with confounding variables as fixation technique was not found to be an independent predictor of SF-36 outcomes in this small cohort.
Analysis of Independent Predictors of Poor Outcomes of Chevron Osteotomy for Hallux Valgus: Focus on Generalized Ligamentous Laxity and Foot Width Changes
Authors: Hwang Yeok Gu , Ahn Jungtae , Kim Tae Yong , Jeong Bi O
Published: October 2019

Category:

Bunion, Midfoot/Forefoot

Introduction/Purpose:

The identification of factors associated with poor outcomes in patients who have undergone chevron metatarsal osteotomy is helpful for predicting postoperative outcomes. The purpose of this study was to evaluate the impact of generalized ligamentous laxity and various clinical risk factors on the radiological and clinical outcomes of chevron osteotomy for hallux valgus.

Methods:

A total of 135 patients (137 feet) who underwent chevron metatarsal osteotomy for hallux valgus deformity were included in this study. The mean follow-up duration was 5.6 years (range, 2–10.4 years). Generalized ligamentous laxity was assessed in all patients. After assessing the clinical outcome after chevron osteotomy for hallux valgus using the American Orthopedic Foot and Ankle Society scores - Hallux Metatarsophalangeal-Interphalangeal scale (AOFAS score), the clinical and radiological risk factors that affect postoperative outcomes were analyzed with bivariate and logistic regression analyses.

Results:

The average AOFAS score improved on surgical treatment from 51.4 ± 13.5 preoperatively to 86.0 ± 12.1 at the last follow-up (P < 0.001). Patients with generalized ligamentous laxity showed no significant difference in radiological and clinical parameters compared to non-laxity patients. According to bivariate and multivariate logistic regression analyses, second plantar callosity on the metatarsophalangeal joint before surgery and the ratio of foot width difference after surgery were significantly associated with clinical outcome after surgery.

Conclusion:

In the surgical treatment of hallux valgus, more careful surgical technique is required for patients with second plantar callus on the metatarsophalangeal joint before surgery, and efforts are needed to reduce foot width through surgical treatment.
Arthroscopically Assisted Bone Pegs Fixation Without Malleolar Osteotomy for Osteochondral Lesion of Talus
Authors: Park Chul Hyun
Published: October 2019

Category:

Ankle, Arthroscopy

Introduction/Purpose:

Several surgical treatments have been suggested for osteochondral lesions of talus (OLT). Fixation of osteochondral fragment using bone pegs is physiologic and does not require removal of implants and has no risk of foreign body reaction. However, this procedure commonly requires osteotomy of malleolus to obtain sufficient surgical field. Therefore, it has longer rehabilitation and a risk of malunion of osteotomy site. We have performed bone pegs fixation without malleolar osteotomy through arthroscopic assistant. The purpose of this study was to introduce our technique and to evaluate clinical and radiographic outcomes of bone pegs fixation for OLT.

Methods:

Ten patients (10 ankles) with osteochondral lesions of talus were treated by arthroscopically assisted autogenous bone pegs fixation without malleolar osteotomy. Intraoperative assessments were evaluated site of lesion, size of fragment, and number of pegs. Clinical assessments were evaluated using VAS and AOFAS score preoperatively and at last follow-up. And SF-36 and ROM of ankle (comparing with uninvolved ankle (%)) was evaluated at last follow-up. Radiographic assessments were evaluated according to criteria as described by Kumai et al.

Results:

The lesion was on posteromedial side in 8 patients and anterolateral side in 2 patients. Mean fragment size was 9.6*13.5 mm. And mean number of used pegs were 2.6. VAS and AOFAS score significantly improved from 6.1 and 74.8 preoperatively to 1 and 93.7 at last follow-up. SF-36 was 80.5 at last follow-up. ROM of ankle joints revealed 97% of uninvolved ankle joints at the last follow-up. Radiographic results were good in 4 patients, fair in 5 patients, and poor in 1 patient.

Conclusion:

Arthroscopically assisted bone pegs fixation without malleolar osteotomy could be a treatment option for OTL with large fragment.
Talus Fractures and Concomitant Injuries Patterns
Authors: Ibrahim Ishaq , Ye Michael , Smith Jeremy , Kwon John Y. , Miller Christopher P.
Published: October 2019

Category:

Trauma

Introduction/Purpose:

Fractures of the talus are rare, but serious injuries to the hindfoot associated with high-energy mechanisms in often polytraumatized patients. The collective knowledge regarding talus injuries is lacking in many regards. Limited effort has been previously made to identify and characterize associated injuries ordinarily occurring in conjunction with fractures of the talus. The purpose of the current study was to [1] determine what associated injuries occur in high incidence in patients presenting with major fractures of the talus, and to [2] identify clinical injury patterns that warrant special attention in patients presenting with talus fractures.

Methods:

A retrospective review was conducted for patients with talar body or neck fractures at three level-1 academic trauma centers in Boston, MA between June 1, 2004 and June 30, 2018. Patient charts were reviewed for demographic details, injury mechanism, open versus closed injury status, and all associated orthopaedic and non-orthopaedic injuries identified during the initial patient encounter and hospitalization.

Results:

253 patients met criteria for inclusion. The final study population included 158 (61%) talar neck fractures, 82 (32%) body fractures, and 18 (7%) head fractures. Falls from height, MVC/MCC, low energy falls and sports injuries were the most common mechanisms of injury in declining order. 64% of patients presenting with a talus fracture had at least one other concomitant injury. The table demonstrates the breakdown of associated injuries rates by body area.

Conclusion:

Talus fractures are commonly associated with injuries to different anatomic sites and systems. Trauma to the ipsilateral foot is most common necessitating complete imaging of the foot and ankle in all patients presenting with talus fractures. Trauma to the chest, abdomen, and pelvis occurred most commonly following motor vehicle trauma. Talar fractures and lumbar spine injuries was also observed frequently and underscores the importance of lumbar spine evaluation in patients presenting with major talus fractures, particularly those occurring after falls from height. This study presents valuable information to surgeons when evaluating and assessing injured patients to optimize care for patients.
Functional Capacity Evaluation for Work-Related Injuries to the Foot and Ankle is Associated with Low Return to Work Rate
Authors: Idarraga Alexander J. , Wright-Chisem Adam , Bohl Daniel D. , Lee Simon , Lin Johnny , Holmes George B. , Hamid Kamran S.
Published: October 2019

Category:

Hindfoot, Ankle, Midfoot/Forefoot, Injury and Rehabilitation

Introduction/Purpose:

The functional capacity evaluation (FCE) is used to determine a worker’s physical ability after treatment of a work-related injury. This evaluation is a critical determinant in the administration of benefits and the decision to return to work (RTW). The purpose of this study is to characterize FCE results and ability to RTW among patients treated for work- related orthopaedic injuries to the foot or ankle.

Methods:

A retrospective medical record review from the practices of four orthopaedic foot and ankle surgeons was conducted. Inclusion criteria were (1) treatment of a work-related injury to the foot or ankle, (2) at least 2 years of follow-up from the injury, and (3) documentation of an associated FCE. The FCE report and clinic notes were used to determine the patient’s pre-injury job requirement (Department of Labor Office category: light, medium, or heavy), post-injury FCE-determined work ability (light, medium, or heavy), specific FCE- or physician-imposed work restrictions, and clearance for RTW. Patients were considered cleared to RTW if their FCE-determined work ability met or exceeded their pre-injury job requirement and if there were no additional restrictions imposed by the FCE or physician that would prevent them from functioning in their pre-injury role.

Results:

A total of 188 patients met inclusion criteria. Missteps/rotational injuries (44.1%), falls from height (22.3%), and crush injuries (20.7%) were the most common mechanisms. 74.4% of patients had FCE-determined work abilities at or above their pre- injury job requirements, and 63.3% of patients were eventually cleared for RTW. The median time from injury to clearance for RTW was 2.0 ± 1.3 years. Reasons for not being cleared to RTW included failure to meet the pre-injury job requirement (67.2%), specific FCE-imposed limitations (28.3%), or specific physician-imposed limitations (4.5%). Less strenuous pre-injury job requirement was positively associated with both FCE-determined work ability meeting pre-injury job requirement and clearance for RTW (p<0.001 and p=0.034, respectively; Table 1).

Conclusion:

Approximately two-thirds of patients undergoing FCE after a work-related foot or ankle injury are cleared to RTW. However, it takes a median of two years to achieve this clearance. Patients with jobs that are more physically strenuous are less likely to be able to return to those jobs after injury to the foot or ankle.
The Achilles Heel of Rehabilitation: Communication: A First Look at a National Research Survey
Authors: Jenkins David , Urness Daniel , Thompson Austin , Meeker James
Published: October 2019

Category:

Hindfoot, Rehabilitation

Introduction/Purpose:

For decades, there has been much debate over the proper treatment and rehabilitation protocols regarding the management of Achilles tendon ruptures (ATRs). With so much controversy, communication between physical therapists (PTs) and orthopaedic surgeons could prove to be paramount in ensuring successful recovery and return to post- morbid activities. Little research has been done in identifying effective communication modalities between surgeons and PTs and it remains unclear how this dynamic impacts the rehabilitation course. We examined the frequency of how common it is for PTs to receive rehabilitation protocols from referring orthopedic surgeons in patients who suffered Achilles tendon ruptures.

Methods:

A blinded national research survey was conducted of PTs who had treated ATR from 2012-2017. Researchers sought to create a generalizable sample of US PTs by selecting physical therapy clinics located in rural and urban areas of randomly selected states. Those who were actively practicing as a PTs and held a corresponding degree (DPT, MPT, and MSPT) were included. Non-practicing PTs, and those without a degree in physical therapy were excluded. A total of 56 respondents took part in the survey.

Results:

PTs practicing for 10 or more years were more likely to promote slower rehabilitation for non-surgical patients, while PTs with less than 10 years of experience preferred slower progress for operative patients (p=0.04). PTs with 10 or more years of experience were significantly more likely to have patients full weight bearing (FWB) after 6 weeks (p=0.01). PTs were also asked what factor was most important for good ATR outcomes. Three themes emerged, one was good communication between PTs and doctors. One respondent wrote “better communication between MD and PT for best outcomes.” The second theme was timing and implementation of proper clinical techniques such as ”early ROM and weight bearing.” A final theme centered on patient education, especially physicians educating patients on mobility restrictions.

Conclusion:

Despite belief that protocol driven approach improves outcomes, it remains unclear how well applied this is in practice. One of the most common responses given by PTs when asked what the most important factor is to ensure good outcomes in ATRs was good communication between PTs and doctors. This insight juxtaposed with 49% of PTs stating most of their recent patients arrived with no protocol, suggests one way to help improve patient outcomes might be to focus on improving communication between doctors and PTs.
Rotational Distal Chevron Osteotomy for Correction of Hallux Valgus Associated with Metatarsus Adductus and Large Distal Metatarsal Articular Angle
Authors: Jeong Jae-Jung
Published: October 2019

Category:

Bunion

Introduction/Purpose:

Hallux valgus treatment in the setting of associated metatarsus adductus is less common and not well described. The presence of metatarsus adductus reduces the gap between the first and second metatarsals. Consequently, it complicates the measurement of the first-second intermetatarsal angle and can limit the area available for transposition of the first metatarsal head. If distal metatarsal articular angle (DMAA) is also increased here, it is difficult to correct. We investigated the effects of rotational distal chevron metatarsal osteotomy (DCMO) on hallux valgus associated with metatarsus adductus and increased DMAA.

Methods:

Twelve patients, (12 female, 15 feet), of average age 59 (SD 23) with symptomatic hallux valgus associated with metatarsus adductus and increased DMAA underwent a rotation DCMO and were reviewed at an average of 12 months postoperatively. Clinically preoperative and postoperative AOFAS hallux MP-IP scale and satisfaction after the surgery were analyzed. Radiologically hallux valgus angle, the 1st intermetatarsal angle, DMAA before and after the operation was analyzed.

Results:

Distal Chevron osteotomy was done in 15 cases. After DCMO, The distal fragment was translated to laterally as far as possible and rotated to reduce DMAA. Clinically AOFAS scale was increased from 65.3 points preoperatively to 92.2 points postoperatively. Two patients were not satisfied with the results. Radiologically hallux valgus angle was decreased from 21.8° preoperatively to 8.5° postoperatively. The first intermetatarsal angle was decreased from 11.8° preoperatively to 6.7° postoperatively. DMAA was decreased from 15.8° preoperatively to 5.5° postoperatively.

Conclusion:

The rotational DCMO was an effective procedure for correcting hallux valgus associated with metatarsus adductus and increased DMAA. It allowed good realignment of the first MTP joint without the need for lesser metatarsal surgery to reduce the metatarsus adductus.
Safety of Achilles Repair Using the Mini-Open Approach in Supine Position vs Prone Position: A Retrospective Study
Authors: Jones James Rush , McKissack Haley , Jha Aaradhana J. , Moraes Leonardo V. M. , He Jun Kit , Viner Gean C. , Williamson Brooklyn D. , Dahlgren Nicholas , Naranje Sameer M. , Shah Ashish
Published: October 2019

Category:

Sports

Introduction/Purpose:

Surgical repair of the Achilles tendon is a commonly-performed procedure in cases of acute tendon rupture. Open Achilles tendon surgery with traditional extensile approach is most often performed with the patient in prone position, but this can interfere with airway access, put increased pressure on the abdomen, and subject to increase perioperative period and comorbidities. Mini-open approach in supine repair may potentially avoid the risks of the prone position, but the safety and utility of this approach have not been established. The purpose of this study is to compare perioperative outcomes between patients undergoing acute Achilles rupture repair with mini-open approach in the supine position versus traditional approach in the prone position.

Methods:

Patients who underwent surgical repair of acute Achilles rupture between the years 2011 and 2018 at a single institution were retrospectively identified using CPT code 27650. Patients who underwent concurrent procedures for additional injuries were excluded. Charts of included patients were retrospectively reviewed for demographic information, intraoperative characteristics, and postoperative outcomes. Statistical analysis was conducted and p-values =0.05 were considered significant.

Results:

A total of 81 patients were included for analysis, 26 supine and 55 prone. Baseline characteristics were statistically similar between the two groups. Average total time in the operating room was significantly greater among patients in the prone position (118.7 minutes) than those in the supine position (100 minutes) (p = 0.0011). Average surgery time, blood loss, and time in PACU were greater among the prone group than the supine group, although these differences were not statistically significant. Average postoperative pain score, infection rate, dehiscence rate, sepsis rate, and DVT rate were also similar between the two groups.

Conclusion:

The mini open approach in supine position may be advantageous in repair of acute Achilles rupture in that it significantly reduces total time in the operating room while maintaining positive patient outcomes. Prospective clinical studies are warranted to validate these assessments.
Intermediate to Long Term Clinical and Radiographic Outcomes of Triple Arthrodesis: A 422 Case Retrospective Review
Authors: King Jesse , Henrikson Karl , Harper Thomas , Anderson Mike , Stauch Chris , Juliano Paul , Aynardi Michael
Published: October 2019

Category:

Ankle Arthritis, Hindfoot

Introduction/Purpose:

Triple arthrodesis is a commonly performed surgical treatment for hindfoot arthritis and deformity. No study has clearly delineated correlates of both clinical and radiographic outcomes in a sample size this large. The purpose of this study is to explore predictive and demographic outcome measures with long-term followup after triple arthrodesis.

Methods:

With IRB approval, an institutional radiology database was queried for patients undergoing triple arthrodesis between 2004 and 2016, by a single surgeon at a single institution. A total of 465 cases were identified. Pre- and post-operative clinical and radiographic data was collected retrospectively. Demographic and predictive data included: age, Body Mass Index (BMI), American Society of Anesthesiologists Score (ASA), Charleston Comorbidity Index (CCI), diabetic status, osteoporosis, hypothyroidism, and neuromuscular disease status. Clinical outcomes including infection rate, reoperation rate and clinical nonunion were recorded. Unintended return to the operating room defined clinical failure. Radiographic data including non-union rate, pre- and post- operative ankle degenerative joint disease was also recorded. Statistical analysis was then performed to evaluate the relationship between predictive measures and various outcomes including reoperation, infection, and non-union rates. 23 cases were lost to follow-up.

Results:

A total of 442 feet (397 patients) were analyzed. The average age was 54 years (14 to 85) with the majority of cases being female (60%). Average follow up was 593 days (40 to 4079). Overall failure rate was 13.7% with clinical nonunion rate of 4.5%. Infection rate was 5.9%. Mortality rate was 0% at 2 years post-operatively. Predictors of failure included: increased BMI, elevated ASA, history of diabetes, underlying neuromuscular disorder (Figure 1). We found no significant difference between pre and post-operative degenerative joint disease rates in the midfoot (9.4%, 12.5%) and ankle (11.7%,13.7%), respectively.

Conclusion:

Triple arthrodesis is a highly effective procedure for treating hindfoot arthritis. Certain predictive measures including BMI, ASA score, diabetic status and underlying neuromuscular disorders significantly correlate with radiographic union. Additionally, diabetic status significantly correlates with infection status postoperatively. An understanding of these predictive measures may help surgeons in their preoperative planning to improve their clinical and radiographic success rates.
Three Dimensional Analysis of Symmetry and Morphometry of the Bilateral Tarsal Bones Using Weightbearing Computed Tomography
Authors: Konow Tobias , Cain Jarrett D. , Siegler Sorin
Published: October 2019

Category:

Hindfoot

Introduction/Purpose:

Surgical restoration of the morphology of deformed tarsal bones caused by severe arthritis and complex fracture may require surgical procedure such as custom 3D printed total talar replacement, extensive bone reconstruction of complex fractured bones, etc. There are variations in the tarsal bones between individuals and with advances in medical imaging/personalized manufacturing techniques such as additive manufacturing; reliance on the contralateral side of the patient becomes important. The purpose of this study is to evaluate the left to right symmetry characteristics of tarsal bones utilizing weightbearing computed tomography in order to effectively and reliably use the 3D morphology of the contra-lateral foot.

Methods:

15 bilateral data sets from weightbearing CT scans were used from a foot and ankle unit. The images were processed to produce 3-dimensional computer models of the distal tibia, talus, talar dome and calcaneus. The left and right tarsal bones in each pair were first mirror-imaged and then registered using a 3D optimal registration technique. After the registration, a distance-mapping algorithm was used to determine the surface-to-surface distance distribution between the paired and registered bones (Figure 1). Maximum surface-to-surface distance indicated the level of asymmetry between the bones. In addition, the volume and surface area of each bone was established and the percentage difference in volume and surface area were established providing an additional measure of left-to-right asymmetry. Figure 1 – Surface-to-surface distance map shiwing the left-to-right deviations (in millimeters) for a talus and distal tibia for one subject.

Results:

The results indicated a left-to-right volume mean difference of less than 2.6% for the talus, 3.1% for the distal tibia and 2.3% for the calcaneus. The mean difference of the surface area was 2.4% for the talus, 1.9% for the distal tibia and 1.6% for the calcaneus. The distance mapping showed a maximum average surface-to-surface left-to-right deviation of 0.8 mm for the talus, 0.4 mm for the talar dome, 0.65 mm for the distal tibia and 0.95 mm for the calcaneus.

Conclusion:

Based on the results of this study, morphometric analysis showed high level of bilateral symmetry indicating that restoration of the tarsal bone based on the contra-lateral foot is a feasible and reliable approach. The study established the level of confidence with which such an approach can be implemented.
Comparative Analysis of Dorsal Nerve Transfer vs Dorsal Neurectomy in Morton’s Neuroma
Authors: Koti Manjunath , Marhoon Zaid , Parikh Mirant , Edwards Max , McAllister Jack
Published: October 2019

Category:

Lesser Toes, Midfoot/Forefoot

Introduction/Purpose:

Comparative analysis of Dorsal Nerve Transfer and Dorsal Neurectomy in Surgical management of Morton’s Neuroma

Methods:

This clinical audit was conducted on patients who had undergone surgery for Morton’s neuroma (MN) between 2002 and 2014. Data was collected using an in-depth review of patients’ case-notes. During the period studied, there were a total of 77 patients, 4 the DNT and 40 in the DN groups. The key indication for surgery in all cases reviewed was failure of the condition to improve using conservative methods. A telephonic survey with Primary outcome measure being Coughlin’s Overall patient’s satisfaction criteria and secondary outcome measures were resolution of sensory symptoms and any footwear restrictions.

Results:

The results of this clinical study shows excellent to good results with the Dorsal nerve transfer group (84%) and Dorsal neurectomy (80%). There were poor results in 11% in the DNT group and 15% in the DN group. Key advantages of Dorsal nerve transfer are better resolution of sensory symptoms in the toes (82%) when compared to Dorsal Neurectomy (65%). 7% reported Nov change and 11% were worse after surgery. 20% had no change and 15% were worse following surgery in DN group. Around 83% had no restriction wearing any footwear in the DNT group when compared to 80%. 17% in the DNT group and 20% were in the DN group wore modified or shoes with no heels.

Conclusion:

In general there is no significant difference in the outcome of the two surgery all procedures. Key advantages of Dorsal nerve transfer is better resolution of sensory symptoms in the toes (82%) when compared to Dorsal Neurectomy (65%). Around 83% in DNT group and 80% in DN group had no restriction wearing any footwear gain is almost similar in both groups in the DNT group. Whilst Dorsal nerve transfer is a slightly longer procedure than Dorsal neurectomy as some problems were encountered relating to mobilising the nerve due to overlying prominent blood vessels or nerve anomalies.
The Effect of Subtalar Motion on Calcaneal Osteotomies
Authors: Krause Fabian , Zderic Ivan , Gueorguiev Boyko , Schmid Timo
Published: October 2019

Category:

Ankle Arthritis, Hindfoot

Introduction/Purpose:

Background There is evidence that the subtalar joint may compensate for supramalleolar deformities and thereby slower or halt progression of ankle arthritis. The mobile subtalar joint may also compensate for the effect of realigning osteotomies of the calcaneus and the tibia. The compensation is limited by the joint orientation and limited ROM (arthritic joint, tarsal coalitions, previous fusion).

Objectives:

The hypotheses are: - the curvature of posterior facet influences subtalar ROM - subtalar ROM influences subtalar compensatory capacity - there is compensation of realigning osteotomies through a mobile subtalar joint, resulting in a less effective correction of weightbearing axis - the osteotomy of the calcaneus (COT) is more affected by the compensation than the supramalleolar tibia osteotomy (SMOT)

Methods:

11 fresh-frozen human lower leg cadaver were mounted into a carbon frame. High resolution ankle TekScan sensors were fixed in the ankle joint via anterior arthrotomy. 300 N load were applied according to half body weight and Achilles tendon pull was simulated. The center of force (COF) migration, max. pressure (Pmax), and the area loaded were measured in the ankle with 10 mm varus / valgus sliding calcaneus osteotomy and 10° varus / valgus SMOT. A CT evaluation of subtalar anatomy (curvature of posterior facet) was conducted and the correlation of posterior facet curvature and subtalar motion and the correlation of subtalar motion and SMOT/COT effect calculated.

Results:

The COF migration was significant for valgus COT and for both SMOT versus the initial position, while the varus SMOT versus the varus COT. Pmax and area loaded changed but not significantly. There was a significant correlation of posterior facet curvature and subtalar motion (r = 0.87), a moderate inverse correlation of subtalar motion and COT effect (r = -0.52), and a poor inverse correlation of subtalar motion and SMOT effect (r = -0.27). In contrast, in a previous study with a stiff cavovarus model significant COF migration and peak pressure changes were found in the ankle joint for all lateral closing SMOT and valgus COT.

Conclusion:

The compensatory capacity of mobile subtalar joint limits effect of COT more than SMOT, likely because the subtalar joint is closer to COT than to SMOT. Biomechanically, the COT is therefore less effective in influencing ankle joint pressure than SMOT. The effect of the COT is more reliable in stiff subtalar joints. The curvature of posterior facet correlates with subtalar ROM.
Arthroscopic Lift, Drill, Fill and Fix (LDFF) for Talar OCDs Stands the Test of Time: Mean 5 year Follow-Up Results in 25 Patients
Authors: Lambers Kaj , Altink Nienke , Dahmen Jari , Stufkens Sjoerd , Kerkhoffs Gino
Published: October 2019

Category:

Ankle, Arthroscopy

Introduction/Purpose:

The purpose of this study was to describe the long-term clinical and radiological outcome of a new arthroscopic fixation technique for primary osteochondral talar defects: Lift, Drill, Fill and Fix (LDFF).

Methods:

Twenty-five patients underwent an arthroscopic LDFF surgery for osteochondral talar defects. Two of these patients underwent surgery on both ankles. During the LDFF technique, the OCD was identified after which an osteochondral flap was created and lifted (lift-phase). The bone flake of the OCD as well as the osteosclerotic area of the bed was drilled (drill phase). Cancellous bone was harvested from the distal tibia and transported into the defect until there was sufficient substantial filling (fill phase). Finally, the osteochondral flap was fixed with an absorbable biocompression screw (fix phase). The mean follow-up was 63 months (SD 9.2). Pre- and postoperative clinical assessment included the Foot and Ankle Outcome Score (FAOS) and the numeric rating scales (NRS) of pain at rest and during walking. Remodeling and bone ingrowth after LDFF were analyzed on computed tomography scans during follow-up at one year after the surgery.

Results:

All patients were available for final follow-up. At final follow-up, LDFF led to a significant improvement of the NRS of pain during rest and the NRS of pain during walking in all patients. The FAOS significantly improved on all 5 subscales: pain, symptoms, activities of daily living, sport and recreation and quality of life. The NRS of pain at rest significantly improved from 2.3 to 1.0 (p = 0.01), and pain with walking significantly improved from 5.7 to 1.6 (p < 0.001). In total 24 out of 25 patients, and 26 out of 27 ankles, showed remodeling and bone ingrowth on CT scans 1 year after the arthroscopic fixation procedure. No complications occurred.

Conclusion:

Arthroscopic LDFF of an osteochondral talar defect shows good long-term results at 5 year follow-up after surgery. Although the radiological results at 1-year follow-up and the long-term clinical results are encouraging, more patients and long- term radiological follow-up is necessary in order to identify prognostic factors on outcomes.
Clinical Outcomes of Osteochondral Lesions of the Tibial Plafond Following Arthroscopic Microfracture
Authors: Lee Wonyong , Park Joseph S. , Cooper Minton T. , Perumal Venkat
Published: October 2019

Category:

Ankle, Arthroscopy

Introduction/Purpose:

There is little data regarding osteochondral lesions of the tibial plafond with only a few studies reporting clinical outcomes after arthroscopic treatment. The purpose of this study is to evaluate the clinical outcomes and the level of sports activities following arthroscopic microfracture for osteochondral lesions of the tibial plafond.

Methods:

A retrospective review was conducted for all patients who underwent arthroscopic microfracture surgery for ankle osteochondral lesions from January 2014 to June 2017. For functional evaluation, the Visual Analog Scale (VAS) pain score, Foot and Ankle Ability Measure (FAAM) score, and Short Form-12 (SF-12) general health questionnaire were used. We also investigated the level of sports activity before and after the surgery.

Results:

16 patients were included in the study, and the mean follow-up period was 29.8 months. The mean FAAM score was significantly improved from 57.6 (range, 6.0-88.9) for the activities of daily living subscale and 34.5 (range, 3.1-92.6) for the sports subscale to 84.3 (range, 46.4-100.0) and 65.2 (range, 23.3-55.1) for each subscale respectively at the final follow-up. There were also significant improvements in SF-12 score, from 36.3 (range, 23.3- 55.1) to 46.0 (range, 18.9-56.6) for SF-12 PCS, and from 41.3 (range, 14.2-65.0) to 52.6 (range, 32.8-60.8) for SF-12 MCS at the final follow-up. Although 16 of 16 (100%) were able to return to their sports activity, the level of sports activity was lower than their level before the surgery.

Conclusion:

Arthroscopic microfracture provided satisfactory clinical outcomes for osteochondral lesions of the tibial plafond. Though one hundred percentage of patients were able to return to sports activity after the surgery, the level of sports activity was lower than their level before the surgery.
Impact of Early Weight-Bearing Following Ankle Arthroscopy and Microfracture of Talar Osteochondral Defects
Authors: Lefebvre Thomas , Scott Daniel J. , Peterson Jonathan , Adams Samuel , Amendola Annunziato
Published: October 2019

Category:

Arthroscopy

Introduction/Purpose:

Ankle impingement and ankle osteochondral defects are common problems seen by foot and ankle specialist that often go on to require surgical managment. After conservative treatment fails, ankle impingement is often managed by arthroscopic debridement, whereas ankle OCDs are often treated with ankle arthroscopy and microfracture as a first line treatment. However, surgeons have various treatment protocols post-operatively after these procedures, with some surgeons allowing immediate weight bearing, were as other surgeons restrict patients weight bearing. There is similar heterogeneity in the manner of immobilization post-operatively. The purpose of this study is to retrospectively review the outcomes of patients undergoing ankle arthroscopy and micro fracture, to determine if immediate weight bearing or removable immobilization had any impact on outcomes.

Methods:

We retrospectively reviewed 79 patients at our institution who underwent ankle arthroscopy with microfracture for talar osteochondral defects over 3 years. This included surgeries performed by one of 7 fellowship trained foot and ankle surgeons at our institution. Each surgeon had different protocols for post-operative weight bearing and immobilization, allowing for a comparison of various post-operative protocols. Patient outcomes were reviewed pre-operatively and post-operatively including age, sex, comorbidities, etiology of talar pathology, post-operative weight bearing status, time to first weight bearing, as well as method and length of immobilization, VAS scores, range of motion, and complications. Clinical outcomes such as time to return to work and return to sport were also evaluated.

Results:

The average patient age was 38. 42 patients (53%) had an additional procedure performed at the time of ankle arthroscopy and microfracture. There was no significant difference in the average pre-op and post-op VAS or range of motion between the immediate weight bearing group and the delayed weight bearing group. There was interestingly a trend towards lower VAS scores in the immediate weight bearing group (1.4 vs 2.6).

Conclusion:

Following ankle arthroscopy and microfracture, we found no difference in VAS, range of motion, or complications when allowing immediate, full weight bearing as well as using removable immobilization as compared to a variety of other protocols at early follow up. In fact, there was a trend towards lower VAS scores in the immediate full weight bearing group. Though this study has early follow up, it does suggest at least the equivalency of allowing immediate weight bearing and removable immobilization following ankle arthroscopy and talar microfracture.