bluuebunny/crossref_metadata_2025_split huggingface dataset:
Predictors of Malreduction in Zone II and III 5th Metatarsal Fractures Fixed with an Intramedullary Screw: A Retrospective Analysis
Authors: Khurana Ankit , Pitts Charles C. , Alexander Bradley , Patel Akshar , Sutherland Charles R. , Greco Elise M. , Cage Benjamin B. , Shah Ashish 
Published: November 2020

Category: Midfoot/Forefoot; Sports Introduction/Purpose: Percutaneous fixation of 5th metatarsal fractures may lead to malreduction due to improper implant selection and placement. Our aim was to test the effects of screw entry, length, and diameter on malreduction, delayed union, non-union, or refracture. Methods: We retrospectively reviewed zone II and proximal zone III 5th metatarsal fractures managed with intramedullary screw fixation. Comparisons were made between plantar cortex distraction/lateral cortex distraction and ratios of screw length, diameter, and entry point using multiple regression analysis. A further analysis was carried out between time to union and distraction in the lateral and plantar cortices. Results: Plantar and lateral gap were both correlated with entry point ratio on lateral and AP view respectively (p<0.001 for both views). We did not see an association between plantar and lateral gap with screw diameter ratio (p=0.393 for AP and p=0.981 for lateral) or screw length ratio (p=0.966 for AP and p=0.740 for Lateral). Ratio of postop/preop apex height on AP and lateral showed correlation to presence of lateral and plantar fracture gap respectively (p<0.0001). Presence of a plantar gap did have a slight influence on time to union (p=0.044). Most fractures showed radiographic union at 12 weeks (38/44 that were followed until union). There were no refractures or nonunions as per available records. Conclusion: Our study shows that screw length and diameter did not lead to significant plantar or lateral fracture site distraction. However, entry point had a significant effect on plantar and lateral gap on post-operative x-ray. Patients with a plantar gap did have an increased risk of delayed union. Entry point should be given more significance rather than screw diameter and length in managing zone 2/3 fifth metatarsal base fractures. This is contradictory to existing radiologic studies. [Table: see text]
A Staged Treatment Algorithm for the Management of Severe Charcot Hindfoot Arthropathy, using Tibiotalocalcaneal Arthrodesis with Femoral Head Allograft
Authors: Khwaja Ansab M. , Manoharan Aditya , Khwaja Ansab M. , Sorenson Jacob , Etebari Cyrus V. , Latt L. Daniel 
Published: November 2020

Category: Diabetes; Ankle; Diabetes; Hindfoot Introduction/Purpose: Charcot neuroarthropathy of the hindfoot (Brodsky type 2 and 3) can involve significant talar collapse / bone loss leading to hindfoot instability, the goal of treatment to create a stable plantigrade shoeable ulcer and infection free foot. This can often be achieved with tibiotalocalcaneal (TTC) arthrodesis but a plantigrade foot can be challenging in setting of significant talar bone loss. Structural allograft has been used in association with TTC fusions in a number of settings but not explored in the treatment of charcot hindfoot. The goal of this study was to examine the outcomes of structural allografting combined with TTC arthrodesis for the treatment of charcot hindfoot. Methods: Retrospective review of all patients treated at our institution with a Brodsky type 2 or 3 was performed over a five year period from 2014 - 2019. We identified twenty-two patients, 12 males and 10 females with a mean age of 57 years. All underwent surgery by the senior author, a fellowship trained foot and ankle orthopedic surgeon. Patients with infection were treated with antibiotics and a Taylor spatial frame prior to definitive stabilization. Non-infected patients were either placed in a total contact cast (TCC) if they were in active charcot or underwent primary charcot reconstruction. If after initial treatment patients had a plantigrade foot, they were placed in stiff soled rocker bottom shoe with custom accommodative insoles. Patients who did not have a plantigrade foot underwent TTC arthrodesis to achieve this. Femoral head allograft was used if excessive talar bone loss or collapse of the hindfoot was noted. Results: At final follow up 13 patients (59%) of the cohort achieved grade 1, an infection and ulcer free plantigrade foot that was able to fit in a shoe. 7 (32%) of patients achieved grade 2, a plantigrade foot in brace, and 2 (9%) achieved level 3 a plantigrade foot. No patients in this cohort underwent amputation. Average duration of treatment until final status was 18 months (minimum 2, maximum 37), number of interventions 3.9 (minimum 1, maximum 10). Of the twelve patients who required allograft, they averaged 4.25 interventions and average time of 17.6 months until final status. Of those who did not require allograft, they averaged 3.4 interventions with follow up of 11.9 months. Conclusion: Our data suggests that patients with Brodsky type 2 and 3 charcot arthropathy of the ankle and hindfoot even with infection can be successfully treated with staged treatment. This includes external fixation and infection management, followed by tibiotalocalcaneal intramedullary nail fixation with or without femoral head allograft to allow for a plantigrade foot and weight bearing in a stiff soled rocker bottom shoe. Further study is needed to determine long term outcomes and relapse rates.
An Update of Foot and Ankle Fellowship Website Content and Accessibility
Authors: Khwaja Ansab M. , Du Peter Z. , Sherman Nathan , Truchan Lisa 
Published: November 2020

Category: Other; Ankle Introduction/Purpose: The internet is one of the first resources for prospective fellowship applicants, and a previous study evaluated the presence of information present on foot and ankle websites. This study aims to evaluate the accessibility provided via the American Orthopaedic Foot & Ankle Society (AOFAS) websites and individual websites. Methods: The AOFAS website was used to identify the list of foot and ankle fellowship programs. The database information was used to review links to fellowship program websites and corroborate it with accessibility through a Google search. Information from fellowship program websites and the AOFAS was used to analyze the presence of previously described recruitment and educational content, and this analysis was compared to previously reported metrics. Results: Forty-eight orthopaedic foot and ankle fellowship programs were identified. The AOFAS database featured direct links to 19 (40%) fellowship websites with the Google search providing direct links to 35 (73%) websites. From the available program websites, the most common recruitment content was salary/benefits, faculty listing, program contact information (48, 100%), and program description (47, 98%). The most common educational content was presence of research component (44, 92%) and description of rotations/curriculum (43, 90%). Foot and ankle fellowship information markedly improved in domains of salary/benefits, program description, faculty listing meetings/courses, rotations/curriculum, and had less information in the domains of office/clinic information and operative experience. Conclusion: There continues to be substantial variability between foot and ankle fellowship websites and the AOFAS website regarding program content and descriptions. Some information is more readily available, but other domains have less information now than in previously reported research.
Foot and Ankle Fellowship Faculty Research Productivity
Authors: Khwaja Ansab M. , Bridge Nathaniel , Sherman Nathan , Du Peter Z. 
Published: November 2020

Category: Other Introduction/Purpose: Academic productivity within orthopaedic subspecialties is important in developing generalizable knowledge, challenging biases, and evolving practice management. Productivity is linked to academic status and can affect compensation. This study evaluated the research activity of faculty at foot and ankle surgery fellowship programs in the United States and associated Canadian programs. The primary objective was to describe the publishing productivity of American Orthopaedic Foot & Ankle Society (AOFAS) fellowship faculty. Methods: Program characteristics from orthopaedic foot and ankle fellowship programs across the United States and Canada were collected from AOFAS and each program’s respective websites. The studied faculty characteristics consisted of years in practice, academic rank, extent of training, and gender. Specific program characteristics were recorded, including Accreditation Council for Graduate Medical Education approval, academic affiliation, fellow research requirement, number of fellows, number of associated faculty members. Data analysis of faculty productivity (Publications, number of publications in specific journals, number of citations, and Hirsch index [h index]) was gathered using the Scopus database. Results: A total of 48 AOFAS foot and ankle surgery fellowship programs were identified with an associated 185 faculty members. The mean number of publications per faculty member was 44.9 (sd 53.0; range 0-323) with a mean h-index of 11.9 (sd 10.6; range 0-54). One-hundred and forty-four (77.8%) academic-affiliated faculty had a significantly greater number of publications (p<0.01), total citations (p<0.05), and publications in FAI (p<0.05), JBJS (p<0.05), CORR (p<0.05), and JAAOS (p<0.05) compared to the 41 (22.2%) nonacademic faculty. Nonacademic faculty maintained a h-index of 9.5 (95% CI 7-12), while academic faculty had a h-index of 12.6 (95% CI 11-14), which did not meet statistical significance (p=0.062). There were no significant differences between measures of publication productivity in male and female faculty, except for maximum citations in a single paper (67.1 vs 142.3; p<0.05) Conclusion: Academic-affiliated foot and ankle fellowship faculty have higher research productivity than non-academic surgeons. The mean h-index of foot and ankle fellowship faculty was 11.9, which is lower than that reported in sports, joints, and spine fellowship faculty but higher than that reported for hand fellowship faculty. The analyses presented can aid foot and ankle surgeons in assessing their academic productivity. [Table: see text]
Talar-Tarsal Stabilization: Rationale and Preliminary Outcomes
Authors: Khwaja Ansab M. , Stevens Peter , Lancaster Alex 
Published: November 2020

Category: Ankle; Hindfoot Introduction/Purpose: While surgical stabilization of the subtalar joint (arthroeresis) in children remains controversial in the USA, it is practiced worldwide, with reportedly good outcomes. Our purpose is to present a series of patients who met our criteria for calcaneal lengthening, but who opted instead for the less invasive option of talo-tarsal stabilization (TTS). In particular we wanted to assess the incidence of untoward outcomes that may manifest within the first year postoperatively, namely peroneal spasm or painful loosening of the implant, and discuss the management of these problems. Methods: With IRB approval, we conducted this retrospective review of 32 patients (60 feet) who underwent talo-tarsal stabilization (TTS) for flexible planovalgus deformity and had a minimum of 1 year follow-up. The etiology was idiopathic for the majority, with a few being neurogenic or syndromic. The age range at insertion was 6-15 years, with the younger patients having neuromuscular etiology or underlying syndromes. Concomitant procedures, included percutaneous Achilles lengthening (33 feet), Kidner (9), supramalleolar rotational osteotomy (1), and guided growth for ankle valgus (2). We assessed hindfoot flexibility and alignment, obvserved the gait pattern and compared weightbearing AP and lateral radiographs taken preoperatively and at least one year postoperatively. Results: At a minimum of 1 year follow-up, 50 implants (85%) were retained and the patients reported satisfactory outcomes. Henceforth, those patients will be monitored on a prn basis. In the early post-immobilization phase, peroneal spasm occurred in 3 patients (5 feet). This resolved with Botox injection in the peroneus brevis in 3 patients and required transfer of the peroneus brevis to the peroneus longus in one. One patient experienced early migration of hte implants, and these were repositioned with a good outcome. Due to lingering discomfort, Implants were removed in five patients (10 feet = 15 %). None of these patients have collapsed and required salvage hindfoot osteotomy or calcaneal lengthening. Conclusion: For the child with flat feet and unremitting pain talar-tarsal stabilization, combined with other procedures as indicated, offers advantages over the accepted methods of medial shift osteotomy or calcaneal lengthening. It is less invasive, well tolerated and may prove to be definitive. The outcome at 1 year is a good forecast of whether or not further treatment will be required. Osteotomy may be obviated.
Establishing a New Bony Landmark for Safe Screw Insertion in Medial Displacement Calcaneal Osteotomy: A Simulation-Based Approach
Authors: Kim Jaeyoung , Day Jonathan 
Published: November 2020

Category: Hindfoot; Other Introduction/Purpose: Medial displacement calcaneal osteotomy (MDCO) is a commonly performed procedure in flatfoot reconstruction. Fixation is often achieved with screws due to its ability to compress across the osteotomy site. Screws are placed via a free-handed technique without direct fluoroscopic visualization, due to difficulty attaining a simultaneous axial calcaneal view. In addition, the posterior calcaneal tuber translates medially after displacement, resulting in altered anatomical geometry. It is therefore important to establish a reliable external bony landmark when performing free-handed interfragmentary fixation in order to avoid potential screw-related complications and to provide better surgical technique and fixation. The purposes of this study are to validate a new external bony landmark and to establish the appropriate trajectory and screw length for free-hand screw fixation in MDCO. Methods: A total of 84 postoperative computed tomography (CT) scans of MDCO in 70 patients were analyzed. The images were reconstructed using a 3-dimensional simulation program (Vworks 4.0, Cybermed). Virtual screw insertion was simulated by aiming towards two bony landmarks: the base of the 5th metatarsal in the axial plane, and the sinus tarsi in the sagittal plane (Figure 1). A grading system was also utilized to classify scenarios in which the screw breached the distal cortical wall: Grade 1 was defined as contact between the virtual screw and the cortex, Grade 2 as the screw approaching the outer margin of the cortex, and Grade 3 as the screw penetrating the outer cortex. The trajectory angle between the screw and the osteotomy, as well as the screw size, were also measured. Results: The average age of patients was 24.5 (range, 19 to 53), and 100% were males. The average displacement of the posterior calcaneal fragment was 7.3+-1.5 mm (range, 3.9 to 13.8). Among the 84 virtual screws, only five (6.0%) breached the medial cortical wall of the osteotomized calcaneus. All medial breaches were Grade 1. None of the virtual screws breached the lateral cortical wall. Mean trajectory angle between the virtual screw and the osteotomy site was 74.9+-6.7˚ (range, 60.0 to 89.8˚). In the perioperative data, estimated maximum screw length by simulation was 55.6+-4.4 mm (range, 50 to 65). Conclusion: Our results suggest that the optimal trajectory of free-handed screw placement can be determined through simulation of calcaneal interfragmentary screw insertion using postoperative CT imaging. Using this simulation technology, we determined a trajectory towards the sinus tarsi on the sagittal plane and the base of the 5th metatarsal on the axial plane to be a reliable external bony landmark for placement of screws in MDCO. These promising results have potential implications in achieving better fixation as well as improving union rates and operative outcomes.
Surgical Outcomes after Simple Coalition Bar Excision in Naviculo-Medial Cuneiform Coalition in Adults
Authors: Kim Jaeyoung , Day Jonathan , Lee Woo-Chun 
Published: November 2020

Category: Midfoot/Forefoot; Other Introduction/Purpose: Coalition of the naviculo-medial cuneiform joint (NCJ) is a relatively rare condition among the tarsal bone coalitions. Thus, optimal treatment is still largely unknown. There is a paucity of literature, with few cases documenting arthrodesis of the NCJ in adults with varied outcomes. As the NCJ contributes to the majority of motion along the medial column of the foot, arthrodesis of the joint may cause excessive stress on adjacent joints. Furthermore, the nonunion rate of NCJ is reportedly high, ranging from 3 to 15%. The purpose of this study was to report the outcomes of simple coalition bar excision in patients with NCJ coalition. Additionally, we investigated preoperative abnormal conditions around the NCJ using weight bearing computed tomography (WBCT). Methods: We retrospectively identified 21 feet in 18 prospectively followed patients from 2010 to 2018 who underwent simple coalition bar excision of NCJ in our institution. Chart review was performed to retrieve demographic data of the patients, clinical presentation findings, and concomitant procedures with coalition bar excision. Radiographically, the location and morphological pattern of the coalition were analyzed. Several angular parameters including medial arch sag angle (MASA) were measured on weightbearing x-rays to see if there are any angular collapse at NCJ after coalition bar excision (Figure 1). The existence of abnormal conditions adjacent to the NCJ such as arthritis of the first and second tarsometatarsal joint (TMTJ) and talonavicular joint (TNJ) were assessed using WBCT (n=17). Clinically, pre- and postoperative visual analogue scale (VAS) and foot function index (FFI) were compared to assess for improvement in patient-reported outcomes. Results: The mean age of the patients was 30.9 years (range, 16-62) and the follow-up was 15.9 months (range, 12-24). Majority of the patient had fibrous coalition at the plantar-medial aspect and only one patient had bony coalition. The morphology of fibrous coalition was classified as irregular (n=8), cystic (n=1), and combined (n=11) based on CT findings. Intraoperatively, the motion of the NCJ was identified in every patient after coalition bar excision. WBCT revealed 15 feet (71.4%) having at least one abnormal finding around the NCJ (First TMTJ plantar gap; n=10, second TMTJ narrowing; n=9, first TMTJ spur & irregularity; n=2, TNJ spur; n=1). Pre- and postoperative MASA did not change significantly (p=0.932). There was significant improvement in VAS and FFI at final follow-up (p<0.001) Conclusion: A considerable proportion of patients with NCJ coalition had at least one radiographically arthritic feature at adjacent joints preoperatively, which may be caused by the restriction in motion associated with NJC coalition. Simple coalition bar excision in adults resulted in satisfactory outcomes without NC joint angular deterioration, while restoring motion at the joint.
Morphologic Characteristics of the Medial Malleolar Fragment based on CT Scan in Ankle Fractures
Authors: Kim Jun-Beom , An Chung-Han 
Published: November 2020

Category: Ankle; Trauma Introduction/Purpose: The aim of this study was to describe and evaluate the morphologic characteristics of the medial malleolar fragment in ankle fractures and suggest the guideline for proper fixation of the fragment Methods: From August 2011 to June 2018, 172 cases were enrolled. There were performed the operation in ankle fractures with a medial malleolar fragment. All cases were divided into three types, based on the transverse fracture line of the medial malleolar by the CT (computed tomography) scan; type 1 was involved in the anterior colliculus, type 2 was the intercollicular groove and type 3 was the posterior colliculus. All cases were classified by Lauge-Hansen classification and compared with the groups statistically. The fixation methods by the groups were reviewed and compared. All cases were analyzed by SPSS 19.0, the p-value was less than 0.05. Results: According to the CT scan, type 1 was 14 cases (8.1%), type 2 was 48 cases (27.9%) and type 3 was 110 cases (63.9%). Based on the Lauge-Hansen classification, SER (supination-external rotation) type was 136 cases(76.4%), PER (pronation-external rotation) was 30 cases(17.4%) and PA(pronation abduction) was 8 cases(4.7%).In SER type, type 1 was 6 cases(4.4%), 2 was 42 cases(30.9%) and 3 was 86 cases(63.2%). In PER type, 1 was 6 cases (20%), 2 was 4 cases (13.3%) and 3 was 20 cases (18.9%). In PA type, 1 was 2 cases (25%), 2 was2 cases (25%) and 3 was 4 cases (50%). The fixation methods were various, such as a tension band wiring, 4.0 cannulated screw, hook plate. Conclusion: The morphology of a medial malleolar fragment based on CT scan in ankle fractures were 3 types. There was common a morphology involved the posterior colliculus, Type 3. We suggest that the operators should choose the proper fixation method by the morphology of the fragment and should be careful to avoid the injury of the posterior tibialis tendon.
Comparison between Osteochondral Autologous Transplantation and Dorsiflexion Closing Wedge Metatarsal Osteotomy for Operative Treatment of Late-Stage Freiberg Disease in Adult Patients
Authors: Kim Sung-Jae , Kim Gablae 
Published: November 2020

Category: Lesser Toes; Midfoot/Forefoot Introduction/Purpose: This study aimed to compare the clinical results between osteochondral autologous transplantation (OAT) and dorsiflexion closing wedge metatarsal osteotomy (DCWMO) in symptomatic adult patients with late-stage Freiberg disease. Methods: Between 2012 and 2017, patients with late-stage Freiberg disease surgically treated with OAT (12 patients) or DCWMO (15 patients) were retrospectively identified. The American Orthopaedic Foot & Ankle Society-lesser MTP- interphalangeal (AOFAS-LMI) score, visual analog scale score for subjective pain, and range of motion (ROM) were determined preoperatively and at final follow-up. Postoperative complications were also recorded. Results: The AOFAS-LMI score at final follow-up was significantly greater in the OAT group than in the DCWMO group (95.7 vs. 87.9, p<0.001), whereas plantarflexion at final follow-up was significantly lower in the DCWMO group than in the OAT group (30.0 degrees vs. 24.0 degrees, p=0.037). The DCWMO group reported more postoperative complications including postoperative joint stiffness, deformity, and pain recurrence. In the OAT group, one patient complained of mild knee pain. Conclusion: OAT seemed a better procedure for late-stage Freiberg disease compared with DCWMO in adult patients in terms of postoperative functional score and ROM, with lesser complication rates.