bluuebunny/crossref_metadata_2025 huggingface dataset:
Dynamic First Tarsometatarsal Instability During Gait Evaluated by Pedobarographic Examination in Patients with Hallux Valgus
Authors: Min Byung Jo , Koo Seungbum , Park Won-keun , Kwon Ki-bum , Lee Kyoung Min
Published: October 2019

Category:

Midfoot/Forefoot

Introduction/Purpose:

This study aimed to investigate the pedobarographic characteristics of tarsometatarsal instability and to identify factors associated with pedobarographic first tarsometatarsal instability in patients with hallux valgus deformity.

Methods:

Fifty-seven patients (mean age, 59.7 years; standard deviation, 11.4 years; 6 men and 51 women) with a hallux valgus angle (HVA) greater than 15° were included. All patients underwent a pedobarographic examination along with weight-bearing anteroposterior (AP) and lateral foot radiography. Radiographic measurements were compared between the two groups with and without pedobarographic first tarsometatarsal instability. The association between the radiographic and pedobarographic parameters of the first tarsometatarsal instability was analyzed using the chi-square test. Binary logistic regression analysis was performed to identify significant factors affecting pedobarographic first tarsometatarsal instability.

Results:

HVA (p<0.001), the intermetatarsal angle (p=0.001), and AP talo-first metatarsal angle were significantly different between the pedobarographically stable and unstable tarsometatarsal groups. There was no significant association between radiographic and pedobarographic instabilities of the first tarsometatarsal joint (p=0.924). HVA was found to be the only significant factor affecting pedobarographic tarsometatarsal joint instability (p=0.001).

Conclusion:

The pedobarographic examination has possible clinical utility in evaluating first tarsometatarsal joint instability in patients with hallux valgus deformity. Patients with greater HVA need to be carefully monitored for the presence of first tarsometatarsal instability, and the necessity of the Lapidus procedure should be considered.
MRI Analysis for Clarification of Mechanism of Ankle Osteoarthritis: When the Talar Tilt Exceeds 15 Degrees, the BME Pattern of the Ankle Are Changes
Authors: Mitsui Hiroyuki , Hirano Takaaki , Akiyama Yui , Endo Wataru , Karube Tomoko , Haraguchi Naoki , Niki Hisateru
Published: October 2019

Category:

Ankle Arthritis

Introduction/Purpose:

In recent years, total ankle arthroplasty (TAA) has been widely performed for severe ankle osteoarthritis (OA). However, TAA is not always successful in cases of advanced varus; in fact, some researchers have stated caution regarding its indication. Previously, to elucidate the pathological condition of ankle OA using MRI, we investigated that confirmed the existence of an association among the Takakura–Tanaka classification, foot and ankle alignment, and bone marrow edema (BME). In this study, we focused on the talar tilt angle and compared the cases of terminal ankle OA as per Takakura– Tanaka classification (stage 3b and 4) wherein this angle exceeded 15° with those wherein it did not exceed in terms of the mode of BME onset.

Methods:

Of 616 cases of ankle OA diagnosed in our hospital between May 2009 and January 2018, we examined the MRI images of 52 feet of 50 patients diagnosed with severe ankle OA. The talar tilt angle with the ankle under load was measured using frontal X-ray, following which the presence/absence of BME was determined by dividing the talus, subtalar, and Chopart’s joints into 22 regions (areas 1–11 and 1’–11’). In statistical analysis, we first obtained the total number of BME incidences for each case. Then, after dividing this disease group into severe varus (SV; talar tilt angle = 15° or more) and mild varus (MV; talar tilt angle < 15°) groups, we compared t-test scores for the respective BME incidence rates. Furthermore, we used Fisher’s exact test to examine differences in terms of BME incidence rates between the two groups for each subdivided region.

Results:

No significant differences were found between the two groups in terms of BME incidence rates for each case. However, the rates in each area were significantly lower in the SV group than in the MV group for area 2 (SV group, 14%; MV group, 57%) and area 4 (SV group, 7%; MV group, 39%), i.e. the SV groups corresponding to the outer surface of the trochlea talar. Conversely, in the subtalar joint, the rates were significantly higher in the SV group than in the MV group for area 10 (SV group, 36%; MV group, 11%) and area 10’ (SV group, 29%; MV group, 5%), i.e. the medial surface of the calcaneus.

Conclusion:

In cases of severe ankle OA wherein the talar tilt angle exceeds 15°, the load exerted on the outer side of the talus decreases in the talar joint, whereas a greater load is exerted on the medial subtalar joint located at the innermost side in the subtalar joint. Differences in terms of the mode of BME incidence in the subtalar joint, which is not replaced with normal TAA, may be a poor prognostic factor for postoperative TAA.
Early Weight-Bearing Does Not Compromise Postoperative Healing in Jones Fracture ORIF
Authors: Moraes Leonardo V. M. , Kelly Stéfani C. , Jones James R. , McKissack Haley , Jha Aaradhana J. , Hsu Alan , Chinnakkannu Karthikeyan , Wilson John T. , Naranje Sameer M. , Shah Ashish B.
Published: October 2019

Category:

Midfoot/Forefoot, Trauma

Introduction/Purpose:

Several controversies persist regarding fracture treatment of the fifth metatarsal base. Due to its low blood supply, Jones fracture has an inherent difficulty of consolidation, and may devolop complications such as delayed union, non- union and refracture. Usually the Jones fracture treatment is done with extended period of non-weightbearing with either nonoperative or operative treatment. The surgery is indicated particularly in athletes or in the setting of nonunion or fracture displacement. The purpose of the present retrospective case series is to assess postoperative outcomes among patients who weight bear earlier than standard practice.

Methods:

We performed a retrospective analysis of the medical and radiographic records from patients who had undergone operative IM fixation of an acute isolated Jones fracture from May 2013 and August 2018. Patients were permitted to weight- bear as tolerated. Demographic information, such as age, gender, body mass index, the use of tobacco, presence of medical comorbidities, and the time of radiographic union were evaluated. Standardized radiographs at 2 weeks, 6 weeks, 3 months and 6 months after surgeries were chosen for evaluation. Radiographic union was defined as bridging in 2 of 3 (medial, lateral, plantar) cortices.

Results:

Twenty one patients were included for analysis. Of these, 14 had at least one comorbidity present at time of operation. Average BMI was 37.6, and average age was 44.8. One patient (4.8%) was lost to follow up, and therefore did not have radiographic results available for review at any appointment. At 6 weeks, 16 of 21 patients showed signs of radiographic healing; 8 were completely healed, and 8 were incomplete. One patient (4.8%) had nonunion, which was documented at 6 week, 3 month, and 6 month readings. None of the 21 patients experienced any other postoperative complications, including infection, wound dehiscence, sepsis, DVT, implant failure, or need for revision surgery.

Conclusion:

Patients who were subjected to early weight-bearing after fifth metatarsal Jones fracture surgery had satisfactory fusion rates with no additional postoperative complications, even despite having high average BMI and multiple comorbidities. We believe that patients can be treated with early weightbearing as tolerated after operative fixation of an acute Jones fracture, and achieve satisfactory outcomes comparable those associated with traditional postoperative protocols.
Anatomical Study of Saphenous Nerve and Great Saphenous Vein Using a Peripheral Vein Illumination Device and Ultrasonography
Authors: Ota Yuki , Nakasa Tomoyuki , Ikuta Yasunari , Tsuyuguchi Yusuke , Kanemitsu Munekazu , Adachi Nobuo
Published: October 2019

Category:

Ankle, Basic Sciences/Biologics

Introduction/Purpose:

Usefulness of ultrasonographic guided saphenous nerve block is well known for perioperative pain management of foot and ankle surgery. However, in some cases it may be impossible to identify the saphenous nerve, especially women or obese patients, so successful rate of ultrasonographic guided saphenous nerve block was reported 70 to 80%. Previous reports demonstrated that the saphenous nerve is running adjacent to the greater saphenous vein, which suggests that the greater saphenous vein can be an indicator to identify the saphenous nerve. The purpose of this study was to examine anatomical relationship between the saphenous nerve and the greater saphenous vein which is depicted using the near-infrared (NIR) vascular imaging system, the Vein Viewer Flex®.

Methods:

Thirty legs as 15 healthy subjects (13 males, 2 females) were included in this study. Average age was 34.2 ± 3.2 years old. In a supine position, the knee joint was flexed 60 degrees with mild flexion, abduction, and external rotation of the hip joint, and the greater saphenous vein was depicted using the Vein Viewer Flex® on the skin of the lower extremity. The vein visualized as a green light was then marked using the skin marker. (Figure 1). After marking the greater saphenous vein, the greater saphenous vein and saphenous nerve were identified under ultrasonography at 5 cm distal from the medial knee joint space (Figure 2). The distance between the greater saphenous vein which was marked using the Vein Viewer Flex® and the saphenous nerve was measured in the ultrasonography images. The circumference of the leg (COL) was also measured.

Results:

The course of the greater saphenous vein could be depicted by the Vein Viewer Flex® in all cases, and it was confirmed by ultrasonography. It was confirmed that the saphenous nerve was located under the sartorius fascia and it was running posteromedially in parallel of the greater saphenous vein. The mean distance from the saphenous nerve and the greater saphenous vein was 7.9 ± 2.7 mm. There was no significant difference between left and right legs (right: 7.9±2.8 mm, left: 8.0±3.0 mm, P=0.95). The mean COL was 34.2 ± 1.9 mm, and there was a moderate positive correlation (r = 0.45).

Conclusion:

This study revealed that the saphenous nerve is running in parallel of the greater saphenous vein which can be depicted by the Vein Viewer Flex®. Ultrasonography after depicting greater saphenous vein enabled to confirm the saphenous nerve with certainly and noninvasive. These findings suggested that the combination of the Vein Viewer Flex® and ultrasonography enables the saphenous nerve block to be more reliable procedure even the saphenous nerve is hardly identified by the ultrasonography.
Outcome of Turf Toe Injuries in NFL Players
Authors: Parekh Selene G. , Parekh Tejas J.
Published: October 2019

Category:

Midfoot/Forefoot, Sports, Trauma

Introduction/Purpose:

“Turf toe” is an injury to the great toe’s metatarsophalangeal joint capsule. The increase in artificial turf in the 1970’s was thought to have contributed to increased incidence of this injury in players of the National Football League (NFL). To our knowledge, there are no publications that have critically analyzed the impact of this injury on player performance. The goal of this study was to quantify the impact a turf toe injury has on NFL players, specifically in time to return to competition and their performance post-injury compared to pre-injury.

Methods:

This is a retrospective review of NFL players who sustained a turf toe injury between the 2011-2014 seasons. Online resources including NFL injury reports, player registries, game summary sites, NFL news articles, fantasy football sites and NFL blogs were used to identify players with this injury. Additionally, an injury database from theFantasyDoctors.com was used to further identify injured players. Recorded variables included player age, position, games missed, and type of playing surface on which the injury occurred. The performance of each offensive skill player was analyzed separately by calculating their power rating (total yards divided by 10 plus touchdowns multiplied by 6) for the 3 seasons prior to injury, the injury season (index season) and the 2 seasons immediately following. Injured offensive skill players were then compared to a control group consisting of all running backs and wide receivers without a turf toe injury who competed in the 2012 season.

Results:

71 turf toe injuries in 67 players were identified. Players’ average age was 26.4 years old. Injury by playing surface: 29 grass, 29 turf and 13 unidentified. The average time missed was 3.2 games. 9 players were placed on injured reserve and 8 required surgery. 16 offensive skill players were at or above 200 total points during the 6 observed seasons. The average power rating prior to injury was 105.7 per season (7.3 per game), 87.3 (6.9 per game) during the injury season and 115.5 (8.1 per game) for post-injury seasons. The power rating per season (p=0.53) and per game (p=0.4) was not significantly different after a turf toe injury compared to before. Power ratings were not significantly different from uninjured control players (p=0.24, p=0.27).

Conclusion:

”Turf toe” is a term used for an injury that has a wide spectrum of consequence depending on injury severity. A mild sprain of the great toe should respond well to conservative treatment with rest, taping and possibly an orthotic while a complete tear of the metatarsophalangeal joint capsule typically is season-ending and requires surgical repair. We were unable to show a statistically significant difference in NFL players’ performances after turf toe injury based on power ratings.
Postoperative Pain and Opioid Use Following Surgical Treatment of Ankle Fractures
Authors: Pate Matthew , Hall Jacob , Anderson John , Bohay Donald , Maskill John , Padley Michelle , Behrend Lindsey , Yaldo Omar
Published: October 2019

Category:

Ankle, Bunion, Trauma

Introduction/Purpose:

Chronic opioid abuse is one of the greatest public health challenges in the United States. The most common first exposure to opioids comes from acute care prescriptions, such as those after surgery. Moreover, opioids are often prescribed excessively, with current estimates suggesting ˜75% of the pills prescribed are unused. Ankle fractures are the most common operatively treated fracture in orthopaedic surgery, and management of acute pain following surgery is challenging. The optimal perioperative pain regimen is still a point of controversy, as there is limited data available regarding appropriate amount of opioid to prescribe. This study evaluates opioid prescribing techniques of multiple foot and ankle surgeons, and associated patient outcomes. We aim to help surgeons improve their pain management practices and to limit opioid overprescription.

Methods:

Chart review and phone survey were performed on forty two adult patients within three to six months of ankle fracture fixation at our institution. These patients were offered to voluntarily participate in a standardized questionnaire regarding pain scores, opioid use, non-opioid analgesic use, pain management satisfaction, and patient prescription education.

Results:

57% of patients reported that they were given “more” or ”much more” opioid medication than needed, 38% stated that they were given the “right amount”, and 5% reported that they were given ”less” or “much less” than needed. 40.0% were on opioids prior to operation. 53.5% did not require refill of discharge opioid prescriptions, 30.2% of patients did not fill any posteroperative opioid prescription. 16.3% of patients filled their discharge prescription and at least one additionall refill (mean refill = 2.22). Mean number of reported opioid pills taken after surgery was 17.4. Mean satisfaction with overall pain management at phone follow up was 8.6/10.

Conclusion:

While postoperative pain and management vary substantially, a majority of patients feel that they are given more opioid medication than necessary following ankle fracture repair, and a majority of opioid prescriptions are not completely used. Going forward, it is likely that a majority of patients could experience the same beneficial results with less prescription opioid pain medication, which would reduce overpresciption and potential misuse.
Structures at Risk in the Arthroscopic Brostrom-Gould Procedure: A Cadaver Study
Authors: Pitts Charles C. , McKissack Haley M. , Anderson Matthew C. , Buddemeyer Katherine M. , Jha Aaradhana J. , Wilson John T. , He Jun Kit , Naranje Sameer M.
Published: October 2019

Category:

Ankle, Arthroscopy, Basic Sciences/Biologics, Sports

Introduction/Purpose:

The Broström Gould procedure is the gold standard for repair of lateral ankle ligament injury and ankle instability. This procedure has demonstrated excellent short- and long-term outcomes in the orthopaedic literature. Arthroscopic Broström Gould techniques have become increasingly popular among some foot and ankle orthopaedic surgeons. Typically, this technique requires standard medial and lateral portals along with an accessory lateral working portal. The exact location of this portal is variable within the available described surgical techniques. The objective of this cadaveric study is to establish a standard entry point for and to assess the safety of the accessory lateral portal with respect to nearby anatomical structures.

Methods:

Ten fresh-frozen below-knee cadaver specimens were used. The location of the accessory portal was created 1.5 cm anterior to the distal tip of the fibula. A small vertical incision was made at this point, followed by insertion of a Kirschner wire into the joint. The wire was then gently impacted into the fibula. Superficial dissection was subsequently carried out around the entry point to identify the peroneal tendons, superficial peroneal nerve branches, and sural nerve branches. Structures were marked with colored push pins, and distance was measured between the nearest edge of the Kirschner wire and each of the three anatomic structures listed. Any instances of structural contact or damage were documented.

Results:

The average distance from the Kirschner wire to the peroneal tendon was 16.1 (±4.41) mm. The average distance from the wire to the superficial peroneal nerve and sural nerve was 13.11 (±6.79) mm and 12.33 (±4.08) mm, respectively. There were no instances of injury to any of the studied structures. However, there was a notable amount of variability in the proximity of structures in question for each cadaver. A branch of the superficial peroneal nerve was measured as close as 2 mm and as far as 24 mm in separate cadaver specimens.

Conclusion:

Arthroscopic Broström Gould procedures are a safe and effective method for lateral ankle ligamentous repair but are not without risk. Accessory lateral portal placement is relatively safe but should be meticulously executed to avoid damage to nearby anatomical structures.
Minimum 2 Year Outcomes of a Fixed Bearing Total Ankle Replacement in the United Kingdom
Authors: Reeve William JE , Dearden Paul , Drake Benjamin , Kakwani Rajeshkumar , Aradhyula Murty N , Talbot Nicholas , Hughes Adrian M , Townshend David , Sharpe Ian T
Published: October 2019

Category:

Ankle, Ankle Arthritis

Introduction/Purpose:

The Infinity (Wright medical) total ankle replacement (TAR) has become the most implanted ankle replacement in the UK with a 30.1% share in the most recent 2016 England and Wales NJR 14th report. It is a fixed bearing implant utilising an anterior approach and radiological guidance to aid alignment, and is approved for use in the UK as an uncemented implant.

Methods:

Since introducing the Infinity TAR in June 2014, all implants from two centres in the UK; The Royal Devon and Exeter Hospital NHS Foundation Trust and Northumbria NHS Healthcare Trust, have been followed up prospectively. 113 implants are included with 2 year minimum follow-up, average follow-up being 33 months (24-52). Pre- and post-operative demographic, radiographic and functional outcomes were collected including Visual Analogue Score (VAS), Manchester Oxford foot questionnaire (MOxFQ, UK validated patient reported outcome score) EQ5D (validated quality of life score). Complexity was assessed using COFAS pre-operative grade.

Results:

Implant survivorship was 93.8% at 2 years minimum. Median age was 68 (42-92), male: female 72:41. Mean MOxFQ improved by 28, mean EQ5D by 1.4 and mean VAS by 7. 16 cases had planned additional procedures, 5 required intra-operative medial malleolar fixation. There have been 2 revisions for deep infection, 2 for implant subsidence, 1 for instability and 2 for unexplained pain (6.2%). 5 patients have required further surgery to the ankle and hindfoot with implant retention (4.4%). 3 patients have asymptomatic tibial cysts (3.4%) and 1 patient has an asymptomatic talar cyst (0.9%) - there is no evidence of progression or loosening.

Conclusion:

We report favourable early functional, radiographic and survivorship outcomes of this implant in the UK population.
Retained Missile to the Foot and Ankle: When Should They Come Out?
Authors: Reilly Megan , Luginbuhl Joshua , Thoder Joseph
Published: October 2019

Category:

Trauma

Introduction/Purpose:

Gunshot wounds are common injuries encountered by orthopaedists in urban settings. Retained missiles can lead to significant morbidity and functional impairment. Despite the potential for adverse sequelae, controversy remains regarding the role of routine bullet removal. Suggested indications for bullet removal include those leading to infection and lead toxicity. Bullets located in the palm of the hand, sole of the foot, or intraarticularly are commonly removed as well. Given the unlikeliness of a retained missile sparing the many joints or sole of the foot, we question the indications for conservative management. The purpose of this case series of is to further develop indications for bullet removal from the foot.

Methods:

A medical record search was performed at a single one trauma institution, with high volume of patients with ballistic injury, for patients who underwent bulletectomy from 2008 until 2018. Of the 169 patients originally obtained, 17 patients underwent bulletectomy, with associated irrigation and debridement, of the foot and ankle. The record of each patient in this retrospective case series was individually reviewed for location of retained missile, indications for removal, whether the procedure was performed at the bedside or in the operating room, concomitant injuries or surgeries, and follow up.

Results:

Of the 17 patients with retained bullets removed from the foot and ankle, four (23.5%) were removed at the bedside versus the operating room. Indications for removal were painful palpable subcutaneous position of the bullet (11 or 64.7%), periarticular or intraarticular bullet (five or 29.4%), and infected wound with removal of foreign body to optimize healing (one or 5.9%). The location of the palpable missiles included three on the plantar foot, four on the dorsal foot, and four located in subcutaneous tissues adjacent to the ankle joint. Nine out of seventeen (52.9%) had fractures associated with the retained missile. Of the patients with OR procedure (13), the majority of them (nine or 69.2%) were in the operating room for another procedure as well.

Conclusion:

The indications for bulletectomy of the foot and ankle are not definite, however, it is recommended that bullets located in the weightbearing plantar foot or intraarticularly be removed. After analysis of a seventeen patient retrospective case series, we support these indications but also advocate for the removal of any painful subcutaneous or periarticular bullet, whether under local anesthesia or in the operating room. In our experience, the prominent foot and ankle bullet is often removed during a procedure for another anatomic site. Bulletectomy of the foot and ankle in a stable polytrauma patient should be considered.
Total Joint Replacement of the First Metatarsophalangeal Joint with Roto-Glide as Alternative to Arthrodesis
Authors: Richter Martinus , Zech Stefan , Meissner Stefan , Naef Issam
Published: October 2019

Category:

Midfoot/Forefoot

Introduction/Purpose:

Total joint replacement (TJR) and arthrodesis (A) are treatment options for severe osteoarthritis of the first metatarsophalangeal joint (MTP1). The aim of this study was to compare outcome (clinical and pedographic) of TJR (Roto- Glide) and A of MTP1.

Methods:

All patients that completed follow-up of at least 24 months after TJR and A of MTP1 before November 5, 2018 were included in the study. Preoperatively and at follow-up, radiographs and/or weight-bearing computed tomographies (WBCT) were obtained. Degenerative changes were classified in four degrees. Standard dynamic pedography was performed (percentage force at first metatarsal head/first toe from force of entire foot). Visual-Analogue-Scale Foot and Ankle (VAS FA) and MTP1 range of motion for dorsi-/plantarflexion (ROM) were registered and compared pre-operatively and follow-up. From November 24, 2011 until October 31, 2016, 25 TJR and 49 A were performed that completed follow-up.

Results:

Parameters (average values if not stated otherwise) for TJR/A were preoperatively: age 59/60 years; 7(28%)/14(29%) male; height 168/169 cm; weight 71/72 kg; degree degenerative changes 3.3/3.1; ROM 19.4/0/9.8°//20.3/0/9.2°; percentage force first metatarsal/first toe 7.9/14.6//8.5/15.3; VAS FA 45.9/46.2. Six wound healing delays were registered (TJR 2, A 4) as only complications. Follow-up time on average 45.7/46.2 and range 25.0-80.3/24.1-81.1 months. VAS FA at follow-up was 73.4/70.2.; percentage force first metatarsal/first toe 15.8/5.8//12.3/10.8; ROM 35.6/0/10.5°//10.5/0/0. Parameters did not differ between TJR and A (each p>.05) except higher force percentage first toe and lower ROM for A at follow-up (each p<.05). VAS FA and pedography parameters improved for TJR and A between preoperatively and follow-up, ROM increased for TJR and decreased for A (each p<.05).

Conclusion:

TJR and A were performed in similar patient cohorts regarding demographic parameter, degree of degenerative changes, ROM, pathological pedographic pattern, and VAS FA. TJR and A improved pathological pedographic pattern and VAS FA at minimum follow-up of 24 months. TJR additionally improved ROM and showed better pedographic pattern (and not different to physiological pattern) than A. Survival rate of TJR was 100% up to 6 years. In this study, TJR was a valuable alternative to A for treatment of severe MTP1 osteoarthritis.
Ankle Range of Motion after Total Ankle Replacement with and without Heel Cord Lengthening
Authors: Ruiz Roxa , Krähenbühl Nicola , Barg Alexej , Hintermann Beat
Published: October 2019

Category:

Ankle, Ankle Arthritis

Introduction/Purpose:

Though total ankle replacement (TAR) has become a well-accepted alternative to fusion for treatment of end-stage ankle osteoarthritis (OA), controversy still exists regarding the appropriate indications. In 80% of the cases, trauma accounts for the primary cause of end-stage ankle OA. In these cases, the soft tissue conditions are often poor and the remaining ankle range of motion (ROM) limited. Additionally, performing a heel cord lengthening (HCL) should theoretically increase ankle ROM. However, it remains unclear to which extent a preoperative stiff ankle can become mobile after a TAR, with or without a HCL. The purpose of this study was to assess the gained ROM after TAR in end-stage ankle OA, and whether it is beneficial for patients who additionally underwent a HCL.

Methods:

Out of 605 primary TAR performed at our institution between 2006 and 2015, 288 ankles (280 patients; age 64.1 [39 – 88]; male, 151; female, 129) were identified with a neutral hindfoot alignment, no degenerative changes or previous fusions of adjacent joints, and no previous ligament reconstruction and tendon transfers at time of TAR. Medial and lateral gutter debridement as well as a complete posterior capsule resection was performed before the prosthesis was inserted. The ankle was then gradually mobilized into dorsiflexion. If a minimum of 10° dorsiflexion could not be obtained, HCL was performed (percutaneous triple hemisection). Postoperatively, the ankle was protected by a walker and weight-bearing was permitted as tolerated. ROM was determined during weight-bearing with the use of a goniometer preoperatively and 2-years postoperatively. Pearson correlation analysis and paired t-test were used for statistical analysis.

Results:

Out of 288 ankles, 41 (14.2%) underwent additional HCL. Preoperative ROM correlated with the ROM 2-years after TAR, independent whether a HCL was performed (p < 0.01) or not (p < 0.01). ROM for the ankles where no HCL was performed was 35° preoperatively and 34° 2-years postoperatively. For the ankles in which a HCL was performed, it was 28° preoperatively and 28° 2-years postoperatively. Pearson correlation analysis showed that patients with a low ROM preoperatively tended to get more motion after TAR, whereas patients with an extensive preoperative ROM even lost some motion after receiving a TAR system (Figure 1).

Conclusion:

The data suggests that a HCL procedure has little potential to ameliorate a preoperative low ROM. A TAR system however, may help increase the ROM in patients with little preoperative ROM while in patients with extensive preoperative ROM it may even cause a loss of ROM. The data further suggests that the heel cord contracture is not the only cause of limited motion in end-stage ankle OA, and that whether TAR nor TAR in combination with HCL should be performed with the goal of gaining ROM for the treatment of end-stage OA.
A Novel Elastic Wrap for Syndesmotic Reduction with Post-Operative CT Scan Analysis
Authors: Schlatterer Daniel R. , Despande Chet , Morgenstein Aaron
Published: October 2019

Category:

Ankle, Trauma

Introduction/Purpose:

Syndesmosis malreductions occur in up to 50% of patients. Several studies concluded that the position of the reduction tines of the periarticular clamp determines the final fibular position. The purpose of this study was to determine if an elastic wrap would provide a more uniform reduction force resulting in an anatomic syndesmosis reduction. We hypothesized that the force applied to the ankle by an elastic wrap would be relatively low and uniform circumferentially around the ankle medially and laterally. Furthermore we thought the ankle wrap would negate the dependency of clamp tine placement and circumferentialy reduce the syndesmosis perfectly. In this series Syndesmotic injuries were treated with the wrap for reduction, screw fixation and post-operative CT scan verification.

Methods:

Syndesmosis malreductions occur in up to 50% of patients. Several studies concluded that the position of the reduction tines of the periarticular clamp determines the final fibular position. The purpose of this study was to determine if an elastic wrap would provide a more uniform reduction force resulting in an anatomic syndesmosis reduction. We hypothesized that the force applied to the ankle by an elastic wrap would be relatively low and uniform circumferentially around the ankle medially and laterally. Furthermore we thought the ankle wrap would negate the dependency of clamp tine placement and circumferentialy reduce the syndesmosis perfectly. In this series Syndesmotic injuries were treated with the wrap for reduction, screw fixation and post-operative CT scan verification.

Results:

In a grossly unstable cadaver ankle model the ankle wrap achieved a perfect reduction every time it was trialed. The pressure film component of this study confirmed a uniform reduction force circumferentially at the ankle under the ankle wrap device of 5-9 pounds per square inch. Post-operative CT scans in 5 cases confirmed anatomic reduction of the syndesmosis in those cases treated surgically with the wrap and screw fixation.

Conclusion:

Malreduction of the syndesmosis can be avoided by using an elastic wrap instead of the standard peri-articular clamp in common clinical practice today.
Outcomes of Defect Management at Tibiotalocalcaneal Fusion Treated with Innovative ‘Bamboo Hut’ Technique
Authors: Shah Rajiv
Published: October 2019

Category:

Hindfoot

Introduction/Purpose:

Tibiotalocalcaneal (TTC) fusion is a salvage procedure for post-traumatic as well as neuropathic cases. Many of these cases are characterised by some or other form of loss of talus resulting in a defect. At TTC fusion, prevention of shortening following such a defect is a challenge. Though allografts have helped solve this issue, they may not be easily available in developing countries. A retrospective analysis of prospectively collected data of 14 cases of TTC fusion with loss of talus is presented here. Cases were managed with innovative defect bridging ‘Bamboo Hut’ technique.

Methods:

Cases with either preoperative or perioperative loss of talus who required bridging of defect were included in the present study. Resultant defect following excision of the talus was bridged with two or three vertically placed fibular strut grafts. Grafts were snugly tied with each other with sutures to prepare a construct like a hut supported with wooden steaks (Bamboo). Fixation was carried out with indigenous TTC nail with a built-in compression device to generate compression of grafts between tibia and calcaneus.

Results:

Present series comprised of 6 post-traumatic cases, 7 cases of diabetic Charcot neuroarthropathy and 1 case of neuroarthropathy following operated meningomyelocele. Cases were followed up for an average period of 36 months with the average time to union being six months. All posttraumatic cases went on to the bony union but two out of eight neuropathy cases ended up in fibrous union with collapse & loss of fixation. Wound healing issues were noticed in two cases. None of the cases required amputation.

Conclusion:

With non-availability of allografts, prevention of shortening at TTC fusion is a challenge. This issue can be successfully managed with innovative ‘Bamboo Hut’ grafting technique, supported with in-built compression of the fusion site with the use of an indigenous nail.
Dynamic Stretching of Fibrillar Collagen Enhances Cross-linking by Transglutaminas
Authors: Shealy Nicolas , Rex James , Bradshaw Amy , Gross Christopher
Published: October 2019

Category:

Basic Sciences/Biologics

Introduction/Purpose:

New approaches to improve tendon repair after injury are an active area of research. Critical properties of tendons are governed by the production and assembly of fibrillar collagens. Cross-linking of fibrillar collagen is a primary factor in determining the function and mechanical properties of the collagen fibers comprising Enzymatic cross-linking by lysyl oxidase in the telopeptide domain of collagen I and III is one determinant of collagen fibril assembly and is the best characterized biochemical cross-link. Transglutaminase catalyzes the modification of lysine residues that in turn form an n-e-glutamyl lysine bond between proteins in the extracellular space. We hypothesize that transglutaminase-dependent modification of collagen in tendons is also a principal determinant of tendon strength and function and is dependent upon tension.

Methods:

3-D collagen gels were generated from acid solubilized type I collagen with telopeptides (Advanced BioMatrix). Collagen gels were plated and loaded into a MechanoCulture FX apparatus (CellScale). Gels were subjected to a 10% stretch for 24 hrs at 37°C at 2hz (dynamic) or no stretch, static controls. Gels exposed to enzymatic cross-linking were incubated with either 2.4 ng of recombinant Transglutaminase 2 (Axxora) in a 10 mM Ca2+ solution. Inhibition and labeling of transglutaminase substrates was performed by incubation of collagen gels with 0.2 mM aminopentyl biotinamide in DMSO. Soluble collagen was separated from insoluble collagen by centrifugation at 10,000G. Insoluble fractions were boiled in SDS-Laemmli buffer prior to separation by SDS-PAGE. Collagen in soluble and insoluble fractions was evaluated by Coomassie stain whereas transglutaminase modification was detected via western blot using streptavidin conjugated horse radish peroxidase to detect biotinylated proteins.

Results:

Evaluation of collagen gels subjected to dynamic versus static stretch revealed minor differences in insoluble collagen incorporation in the two conditions. Notably, higher molecular weight cross-linked forms of collagen appeared to be higher in dynamic versus static gels. In the presence of transglutaminase, differences in higher molecular weight cross-linked forms of collagen, beta-bands, were also detected. Finally, incorporation of biotinylated transglutaminase substrate into collagen alpha bands was enriched in dynamic versus static cultures. Hence, preliminary results support a differential role for transglutaminase modification in collagen under cyclic tension versus static conditions.

Conclusion:

A better understanding of the role of dynamic stretching and differential tension in the regulation of collagen cross- link formation is predicted to contribute to improved strategies to treat injured tendons.
Retrospective Radiographic Evaluation of AugmentTM Bone Graft Fusion
Authors: Shelton Trevor J. , Sheih Alvin K. , Chang Eric , Steele Amy E. , Giza Eric , Kreulen Christopher D.
Published: October 2019

Category:

Ankle, Ankle Arthritis, Hindfoot, Midfoot/Forefoot

Introduction/Purpose:

Augment is the first Food and Drug Administration approved synthetic bone substitute specifically formulated for foot and ankle procedures and have shown results comparable to autograft. Initial studies on the use of Augment for fusion procedures of the foot and ankle are encouraging but there remains a lack of radiographic outcomes on its use. The purposes of this study were to report on the radiographic fusion rate of Augment and identify risk factors for nonunion in patients treated with Augment.

Methods:

After institutional review board approval, a retrospective study was performed of all patients ages 18-85 who underwent arthrodesis of the ankle, hindfoot, or midfoot and used Augment alone or in combination with autograft and/or allograft. Patients were excluded if they did not have regular radiographic follow-up. Each operative report was examined for procedure performed and location of the foot involved. Post-operative radiographs were reviewed to look at union rate following surgery. Patient charts were reviewed for age, gender, Body Mass Index (BMI), smoking history, and diabetes to examine potential risk factors for nonunion. Continuous variables were reported in means ± standard deviations and differences determined between those that fused and those that did not using a Wilcoxon Rank Sums test. Categorical variables reported as number of patients (percent of patients) and differences determined between those that fused and those that did not using a Fisher’s exact test.

Results:

A total of 71 patients (average age at injury 57±14 years; 35 males (49%), 36 females (50%); BMI 31±6) underwent 33 (46%) midfoot arthrodesis, 41 (58%) hindfoot arthrodesis, and 27 (38%) ankle arthrodesis. A total of 58 patients (82%) went on to achieve fusion while 13 (18%) did not. There was no difference in gender (p=0.135), age (p=0.345) or BMI (p=0.196) between those who achieved fusion and those who did not. Patients with diabetes had a greater risk of nonunion compared to those who did not (p=0.033) while current smoking status or revision fusion did not pose a risk factor (p=1.000) (Table 1). There were no differences in part of the foot/ankle involved (p=0.445) or bone graft used (p=0.303).

Conclusion:

This the first study to examine the radiographic follow up of union using Augment. The most important finding of this study is that the rate of fusion in foot and ankle arthrodesis using Augment is near 82%. Diabetes is a risk factor for nonunion when using Augment. Smoking, gender, age, BMI, autograft vs allograft, and part of the foot or ankle fused did not pose a risk factor.
Ankle Distraction Arthroplasty combined with PRP injection for Post-traumatic Ankle Arthritis
Authors: Shi Zhongmin , Gu Wenqi
Published: October 2019

Category:

Ankle Arthritis

Introduction/Purpose:

To summarize and evaluate the surgical technique and clinical outcome of ankle distraction arthroplasty with PRP injection for post-traumatic ankle arthritis.

Methods:

Totally 21 patients of post-traumatic ankle arthritis were treated at the department of orthopaedic surgery, Shanghai Sixth People’s Hospital. They were 13 males and 8 females with an average age of 32.5±6.2 years. The average course of disease were 14.0±2.8 months. After the failure of conservative management for at least 6 months, ankle distraction arthroplasty with PRP injection was performed in all patients. American Orthopaedic Foot & Ankle Society (AOFAS) ankle and hindfoot score system and Visual Analogue Scale (VAS) system were used to evaluate the final overall outcome. The range of motion (ROM) of ankle joint and complications were also recorded.

Results:

Pin tract infection was occurred in two patients, who were cured by alcohol care. 18 patients were followed for an average 36 months. The post-operative AOFAS ankle and hindfoot score was improved from 46.2±7.7 to 79.2±11.6 (t=-14.58, P ＜0.05), while the VAS score was decreased from 6.6±1.1 to 1.8±2.0 (t=16.424, P＜0.0001). The dorsal extension of ankle joint was increased from 1.3±9.3° to 8.1±5.5° (t=-4.675, P＜0.0001) and the plantar flexion was improved from 14.4±6.8° to 26.9±7.3°(t=-7.919, P＜0.05). The radiograph manifested the progressive course of ankle arthritis in four patients, two of which were cured by a salvage ankle arthrodesis by consequence of a failure of conservative treatment for persistent pain and functional limitation.

Conclusion:

The ankle distraction arthroplasty is an effective ankle preserving surgery, which could relieve symptoms, improve functions and delay the course of post-traumatic ankle arthritis
Return to Play and Rehabilitation Protocols following Autologous Osteochondral Transplantation for Osteochondral Lesions of the Talus: A Systematic Review and Meta-Analysis
Authors: Shimozono Yoshiharu , Seow Dexter , Gianakos Arianna L , Chiarello Eugenio , Kennedy John G.
Published: October 2019

Category:

Ankle, Sports

Introduction/Purpose:

Autologous osteochondral transplantation (AOT) has demonstrated favourable outcomes in the treatment of osteochondral lesions of the talus (OLT). Recent studies have reported high rates of return to play sports following AOT for OLT, however variable rates of return to play have been reported ranging from 50 to 95%. In addition, little information regarding optimal standardized rehabilitation protocols and return to play guidelines has been demonstrated. The purpose of this study is to determine the rate of return to play following AOT for OLT by systematic review and meta-analysis and report subsequent rehabilitation protocols.

Methods:

The MEDLINE, EMBASE and The Cochrane Library databases was evaluated according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using specific inclusion/exclusion criteria. The quality of evidence was evaluated using the Modified Coleman Methodology Score (MCMS). Predetermined data was extracted on a datasheet with the return to play calculated as a percentage of patients that returned to sport. Rehabilitation protocols were recorded as the earliest time that range of motion, partial weightbearing and full weightbearing commenced was recorded. The quality of return to play guidelines in each study was evaluated based on the criteria by Zaman et al. Well defined return to play criteria was allocated a score of 4, poorly defined criteria allocated a score between 1 to 3 and no return to play criteria allocated 0. The meta-analysis of return to play was performed using previously published criteria.

Results:

The search strategy yielded 8 studies evaluating 200 ankles with a mean follow-up of 44.3 ± 26.8 months (range, 16 to 84 months), mean age of 31.3 ± 6.92 years (range, 22.7 to 42 years) and mean OLT size of 119.2 ± 35.3 mm2 (range, 68.9 to 180 mm2). The mean time to return to play was 4.55 ± 2.19 months (range, 3 to 6.1 months). The reported rates of return to play ranged from 50% to 95.2%. The accumulative rate of return to play was 83.8% (140/167), with 77.4% (48/62) of athletes returning to pre-injury status. Based on the fixed-effect model, the rate of return to play was 81.5% (Figure 1). The quality of return to play criteria was poor in all.

Conclusion:

This systematic review indicates high rate of return to play following AOT in the athletic population. Rehabilitation protocols were largely inconsistent and were primarily based on individual surgeon protocols. The included studies were of low level and quality of evidence, therefore, further well-designed studies are warranted to sufficiently improve the reporting accuracy for rate of return to play.
Normalization of Microbiome after Diabetic Foot Ulcer Treatment
Authors: Stephens Sebastien , Stephens Alexandre , Platt Simon
Published: October 2019

Category:

Diabetes

Introduction/Purpose:

Diabetic ulcers carry with it extensive morbidity. The microbiome of diabetic foot infections have previously been shown to be polymicrobial. We hypothesized that ulcer treatment would normalize the foot microbiome.

Methods:

Microbiome profiles of the fore, mid and hind diabetic foot. Diabetic foot (with ulcer) were taken pre and post treatment with a combination of surgical debridement, local and systemic antibiotics. 10 subjects were studied. Microbiome graphs and images pre and post treatment of feet are shown.

Results:

The microbiome profile of the diabetic foot almost completely normalized to that of normal flora. Before treatment, the foot microbiome was associated with polymicrobial pathogenic bacteria mostly away from the ulcer. The ulcer itself only contained minimal species, albeit pathogenic bacteria. The differences in profiles between the pre and post treatment were significantly different p < 0.01.

Conclusion:

Chicken or egg, the foot microbiome almost completely reverts to normal flora with simple ulcer debridement and local/systemic antibiotics. Our data point possibly suggest ulcers could be prevented by reducing pathogenic microbiome load (chlorhexidine washes) or microbiome transplants. We next move to controls as a proof of concept.