bluuebunny/crossref_metadata_2025_split huggingface dataset:
Evaluation of the Anterior Talofibular Ligament by Stress Ultrasound for Assessing Generalized Joint Hypermobility
Authors: Song Jaehwang , Kang Chan , Jeon Je Hyung , Ham Chang Uk 
Published: November 2020

Category: Ankle; Basic Sciences/Biologics Introduction/Purpose: Chronic ankle instability with generalized joint hypermobility (GJH) is considered a relative contraindication for the modified Bröstrom procedure. Most clinicians use the Beighton score to assess GJH. However, the Beighton score itself does not involve investigation of the ankle joint. In our experience, resting, longitudinal ultrasound images of the uninjured, intact ATFL frequently show a loose, wavy pattern in patients with high Beighton scores. We evaluated anterior talofibular ligament (ATFL) status according to Beighton score and the manual anterior drawer test (ADT). It was hypothesized that the value of ultrasound for ATFL would be significantly different between participants with GJH (Beighton score >= 5) and without GJH and show a correlation with participant’s Beighton scores and manual ADT grades. Methods: Forty-four healthy young patients (44 ankles) aged 20 to 40 years and without a history of ankle trauma or disease were included in the study. To assess GJH and ankle instability, Beighton scores and manual ADT grades were evaluated, respectively. For the investigation of ATFL, resting and stress ultrasonography were performed to assess its length, height, and thickness. Ultrasound images were taken in resting position and during maximal plantar-flexion and inversion (Figure: Ultrasound images of the ATFL in (a) the resting position and (b) stress position in a 21-year-old woman with Beighton score of 9. Dotted red line: Length, Yellow line: Height, Green double-headed arrow: Thickness). Beighton scores, manual ADT grades, and ultrasound parameters of participants with and without GJH were compared and the correlation coefficients among Beighton scores, manual ADT grades, and the length, height, and thickness of resting and stress ATFLs were analyzed. Results: The participants were divided into two groups, those without GJH (24 ankles) and with GJH (20 ankles). Mean Beighton scores and manual ADT grades were significantly different between the two groups (P < .05). The mean length, height of resting, stress ATFL and mean difference in height between resting and stress ATFL were significantly different between the two groups (P < .05). The resting and stress ATFL length, height, and difference in height between resting and stress ATFL showed a moderately positive linear relationship with Beighton scores and manual ADT grades (P < .05). Among the ATFL parameters, resting ATFL height showed the strongest relationship with the Beighton score (r = 0.763, P < .001) and ADT grade (r = 0.763, P < .001). Conclusion: The ATFL stress ultrasound parameters showed significant differences between participants with high and low Beighton scores and were correlated with Beighton scores and manual ADT grades. We believe that this ankle joint specific method might provide significant, quantitative parameters for assessing GJH in addition to the Beighton score.
Fracture of the Posteromedial Tubercle of the Talus: Case Series of Fifteen Patients Along with Cadaveric Dissection and Anatomic Considerations for Surgical Approach
Authors: Steffensmeier Andrew M. , Matar Robert , Chung David , Yue Ruixian A. , Dixon Tonya L. , Sagi Claude , Laughlin Richard T. , Steffensmeier Andrew M. 
Published: November 2020

Category: Ankle; Hindfoot; Trauma Introduction/Purpose: Fractures of the talus are among the most commonly fractured bone of the foot, with 10 to 21% involving the posterior process. These fractures have not been well characterized or reported in the literature and is limited to case reports and case series. The primary objective of this study is to characterize posterior process fractures, describe a surgical approach for open reduction internal fixation (ORIF) with the use of cadaveric dissection pictures of surgical technique and describe 15 cases. Methods: A search query of the institutional database was performed for all adult patients that sustained talar fractures at the University of Cincinnati Medical Center from 1/1/2010 to 12/31/2018. Patients sustaining posterior process talus fractures who underwent operative fixation and nonoperative treatment were identified. All radiographs and CT images were then reviewed by three orthopedic surgeons and the electronic medical record was reviewed for injury characteristics, method of operative fixation, and postoperative complications. Results: 15 cases of posterior process fractures were identified. Overall, 4 patients had fixation placed in the posterior process fracture while 11 did not. None of the patients who underwent ORIF of the posterior process developed subtalar arthritis at their latest follow-up, while 3 of the 11 (27.3%) that did not receive fixation suffered from subtalar arthritis and 1 (9.1%) required surgery for removal of retained loose bodies. 13 patients (86.67%) initially had plain radiographs that missed the diagnosis. Cadaveric specimens were used to illustrate surgical approach for ORIF of these talus fractures. Anatomic pictures of the surgical dissection were taken to show the extent of exposure to the posterior process fracture using traditional techniques, as well as methods of distraction to enhance visualization are demonstrated. Conclusion: Providers must have high suspicion for posterior process talus fractures as many are missed on the initial radiographs. CT scans are recommended for all patients with subtalar dislocations. Those with subtalar dislocation tend to have comminuted fragments. Significant morbidity is associated with this injury regardless of whether it is treated operatively or nonoperatively. We describe a surgical technique using distractors to adequately visualize the posteromedial process fracture of the talus.
Reliability of Evaluating Methods using Weightbearing Radiograph of the Foot in Lisfranc Injuries
Authors: Sugino Yuki , Yoshimura Ichiro , Hagio Tomonobu , Nagatomo Masaya , Yamamoto Takuaki 
Published: November 2020

Category: Trauma; Midfoot/Forefoot Introduction/Purpose: Lisfranc ligament is a strong interosseous ligament located between the medial cuneiform (C1) and base of the second metatarsal (M2). Lisfranc injuries occur in approximately 0.2% of all fractures and are often overlooked or misdiagnosed. Weightbearing radiograph of the foot has been used as a diagnostic method for Lisfranc injuries; however, there is no study to evaluate the reliability of the measurement techniques on weightbearing radiographs. While several measurement techniques on weightbearing radiograph have been proposed for evaluating Lisfranc injuries, it remains unclear which measurement is the most reliable. This study aimed to evaluate the intra- and inter-observer reliability of the measurement techniques using weightbearing radiographs. Methods: Seventeen patients who were diagnosed with Lisfranc injuries using weightbearing radiographs and were treated with open reduction and internal fixation in our hospital between January 2013 and April 2019 were included in this study. Patients with multiple fractures were excluded. Four observers were selected, of which two were orthopedic specialists with more than six years of experience, while the remaining two were orthopedic surgeons with less than five years of experience. Observers evaluated the intra- and inter-observer reliability of the five measurement points on weightbearing radiographs on the affected and unaffected sides. The measurement points included the proximal, middle, and distal C1-M2 distance and parallel distance of C1-M2 and C1- the medial cuneiform (C2). Results: The proximal, middle, and distal C1-M2 distance and parallel distance of C1-M2 of The affected sides were wider than those of the unaffected sides with significant difference (p<0.01). The middle C1-M2 distance of the affected sides showed the highest intra-observer reliability (0.92) and the second highest inter-observer reliability (0.8). Other measurements of the affected sides showed comparable intra- (0.76-0.91) and inter-observer reliability (0.62-0.84). In addition, the middle C1-M2 distance of the unaffected sides showed the highest intra- (0.76) and inter-observer reliability (0.64); however, all measurements of the unaffected sides showed lower reliability than all measurements of the affected sides. Conclusion: The most reliable measurement point on the weightbearing radiograph was the middle distance of C1-M2. This result may help avoid overlooking or misdiagnosis of Lisfranc injuries.
Minimal Invasive Hallux Valgus Surgery
Authors: Tenenbaum Shay A. , Thein Ran , Ari Erel Ben , Dreiangel Niv , Bariteau Jason T. , Bruck Nathan , Coifman Oded R. 
Published: November 2020

Category: Bunion; Other Introduction/Purpose: Hallux valgus is one of the most common deformities of the adult foot, and can adversely affect quality of life, with common complaints including pain, footwear restrictions and cosmesis. Minimal Invasive Surgery (MIS) has re-emerged lately, gaining growing popularity as a surgical approach for surgical treatment of HV deformity. Advantages such as short operating time, quicker recovery, and fewer complications have attributed to MIS. However published data are still inconclusive. Methods: The study included 40 feet (33 pts) with hallux valgus treated with MIS technique, between Apr 20016 to March 2018. Patients were included only if pre- and postoperative weightbearing X-rays at final followup (min 6m) were available. The average age was 51.3 years (range, 21 to 77), with average follow-up of 12 months (range, 6 to 24). Patients’ radiographic records were studied to evaluate postoperative change in hallux valgus angle (HVA), intermetatarsal angle (IMA) and DMAA. Clinical outcome was recorded with Patient reported outcome questioners PROMS10 and MOXFQ. Results: Following surgery deformity was corrected with preoperative mean HVA of 29.8° and IMA of 14.4° compared to postoperative mean of 7.1° and 4.7°, respectively. Patient reported outcome measures recorded the efficacy of MIS for HV in terms of pain reduction and function improvement. In six feet surgery for hardware removal was performed. In one case non- union was treated with revision surgery. Conclusion: This study shows that MIS for HV is safe, effective and offers satisfactory surgical and clinical results.
2-Week Post-Operative Opioid Use after Primary Hallux Valgus Correction
Authors: Thier Zachary T. , Altobello Kenna C. , Gonzalez Tyler A. , Jackson J. Ben 
Published: November 2020

Category: Bunion; Other Introduction/Purpose: More than 200,000 surgeries for hallux valgus correction occur annually in the United States. Due to the post-operative pain associated with the procedure, opioids are often prescribed to help manage pain. The opioid epidemic has led to a 78-billion-dollar economic impact. Given the lack of objective data on opioid use and the difficulty of addressing a patient’s post-operative pain, we sought to quantify, through a prospective analysis, patient’s narcotic use after hallux valgus surgery. Objective data may help guide the surgeon in the type and number of opioids utilized after surgery. Methods: Adult patients undergoing primary hallux valgus surgery were recruited from two surgeon’s institution. At the pre- operative visit, patients were consented and completed a demographical questionnaire. Data was collected from the operative and PACU record, as well as the 2-week post-operative visit. A simple statistical analysis was performed to determine average quantity and type of opioid and non-opioid pain medication used in the PACU and for post-operative pain management. Results: 33 subjects were prospectively enrolled and followed. The average time until the first post-operative clinic visit was 13.53 days. The average opioid pain medication consumption during this period was 20.766 (0-66) pills, with a morphine milligram equivalents (MME)/kg of body weight at 1.69. (78.8%) were prescribed hydrocodone/acetaminophen 5/325mg and 7 subjects (21.2%) were prescribed oxycodone/acetaminophen 5/325 for post-operative pain management. 84.8% of subjects (28/33) received a local block, including 2 femoral, 2 ankle, 13 popliteal, 3 sciatic, 3 adductor canal, 4 popliteal and saphenous, and 1 popliteal and adductor canal. 24.2% (8/33) of subjects received opioid pain medication in the PACU post-operatively with a MME/kg of body weight at 0.135 per subject. Conclusion: Based on our prospective study, we recommend an initial prescription of 30 5mg hydro/oxycodone pain pills, as this represents the 3rd quartile of consumption.
Efficacy of the Glidepath Technique for Ankle Syndesmosis Reduction
Authors: Unangst Alicia M. , Ryan Paul M. , Harris Mitchell , Song Daniel 
Published: November 2020

Category: Ankle; Trauma Introduction/Purpose: Syndesmotic screw fixation is frequently required in rotational ankle injuries. Fibular malreduction after syndesmotic screw fixation occurs in as many as 52% of cases, which has been shown to detrimentally affect subjective outcomes and increase the probability of developing arthritis. The glidepath technique has been proposed as a useful technique to prevent malreduction. We hypothesize that the glidepath technique reduces the occurrence of fibular malreduction and results in improved outcomes compared to clamping. Methods: A retrospective cohort study comparing 25 patients reduced with a clamp compared to 18 patient using the glidepath technique. The glidepath technique, described by Needleman, the fibula is manually reduced and a Kirschner wire is placed through the fibula and tibia along the transmalleolar axis, parallel to the superior border of the ankle mortise. CT scans of the injured and contralateral ankles were obtained postoperatively to assess reduction. Malreduction is defined as >2mm difference between the anterior or posterior incisura-fibular distance of the injured ankle compared to the contralateral side. Prospective outcomes were assessed using the AOFAS and VR-12 scores at preoperative, 3 month, 6 month and 1 year followup of the glidepath cohort only. Results: We found a statistically significant reduction in malreduced syndesmoses using the glidepath technique when compared with the clamping technique. In our study, 17% (3/18) were malreduced using the glidepath technique, compared with 48% (12/25 patients) with clamping (p=0.005). The three malreductions seen in our study were anterior, we had no posterior malreductions. Compared with the clamping cohort that had 10/25 posterior malreductions and 2/25 anterior malreductions. Mean outcomes at 3,6 and 1 year scores were AOFAS 76, 86,86; VR-12 46,53,50/ 42,44,47 (physical/mental) respectively. Conclusion: Historically, malreduction for syndesmotic fixation is as high as 52%. The glidepath technique is a viable reduction maneuver that has lower rates of malreduction compared to clamping in our study. This is the first ever CT confirmed study measuring syndesmosis reduction utilizing manual reduction. The value of this technique is that is does not require an open reduction, arthroscopic visualization/reduction or CT guidance to achieve syndesmotic reduction.
Analysis of 28 Broken Syndesmosis Screws
Authors: Maten Josh W. Vander , Roebke Logan , Liu Jiayong 
Published: November 2020

Category: Ankle; Trauma Introduction/Purpose: Syndesmosis screw fixation remains a common standard of care in patients with syndesmosis injuries. Screw fracture is a relatively common occurrence in these patients. The purpose of this is study is to examine the screw characteristics of 28 syndesmosis screws that resulted in screw breakage. Methods: This retrospective study examined all tibia procedures from 2008 to 2019 at a level 1 trauma center. Patients that were treated with a syndesmosis screw that resulted in a screw breakage were included for further analysis. In total, 14 patients satisfied this criterion. A comprehensive analysis of the screw characteristics was then performed. Screw angle was determined using the fibular plate as the vertical axis. Distance of screw fracture also used the fibular plate as a reference point. The tibial plafond was used to determine screw placement. Screws were stratified into subcategories based on standard deviation for screw angle and screw placement. Results: 28 screws were analyzed in 14 patients (6 males, 8 females). On average, 2 syndesmosis screws were placed with a range of 1 to 4. Average screw length was 50.54±5.67 (45-65) mm. Average screw width was 3.64±.36 (3.50-4.50). Average angle of screw placement was 88.70±(65.90-99.50). Eighteen (64.29%) of the screws were placed at an angle greater than 90 degrees. Six were between 80-90 (21.42%) degrees. Average height above the tibial plafond was 25.90±(9.75-49.90). Fifteen (53.57%) of the screws were placed between 20-30mm above the tibial plafond. Six (21.43%) were between 10-20 mm. Twelve screw fractures occurred within the fibula, 7 within the tibia, and 2 screws had a fracture within the fibula and tibia. The average fracture distance from the fibular plate was 14.81±2.36(0-36.23) mm. Conclusion: The aim of this study was to examine syndesmosis screw characteristics following fracture. Eighteen of the 28 screws were placed above a 90-degree angle and 15 were placed between 20-30mm above tibia plafond. This may suggest higher risk for screw fracture above 90 degrees and between 20-30mm above the tibial plafond, however, further analysis with more subjects should be done before any determination is made. [Table: see text]
BMI and Comorbidities in Patients with Syndesmosis Screw Breakage
Authors: Maten Josh W. Vander , Liu Jiayong , Roebke Logan 
Published: November 2020

Category: Ankle; Trauma Introduction/Purpose: Syndesmosis screw fixation remains a common standard of care in patients with syndesmosis injuries. Post-operative screw breakage is a common occurrence in these patients. The purpose of this is study is to compare BMI, comorbidities, and characteristics of patients who had a syndesmosis injury repaired with screw fixation resulting in screw failure. Numerous studies (21) have examined patients with syndesmosis screw fracture, focusing primarily on screw characteristics such as width, length, and screw material. Of those studies, only six considered BMI, while only one of the six differentiated BMI between patients with a broken screw and those without. Only three of the studies collected patient comorbidity data. Methods: This study examined all tibia procedures at a level 1 trauma center from 2008 to 2019. Only patients treated with syndesmosis screw fixation that resulted in a screw fracture were included for further analysis. In total, 14 patients satisfied this criterion. A comprehensive analysis of each patients BMI, comorbidities, and characteristics was then performed. Age, gender, height, weight, BMI, smoking status, diabetes, hypertension, alcohol abuse, and soft tissue conditions were all analyzed. Further examination of conditions with potential to impact bone quality such as osteoporosis, osteoarthritis, and rheumatoid arthritis were also included. Results: Eight females and 6 males with an average age of 42.43±13.90(20-43) were included in the analysis. The average number of comorbidities was 2.93±(0-6). BMI average was 38.92±(22.05-56.34) indicating Grade II obesity for the entire patient cohort. Six patients had a BMI > 40 or Grade III (morbidly obese) while only two patients had a satisfactory BMI < 25. All patients in the syndesmosis fracture group had more than one comorbidity apart from a single patient (case 3). Six patients had at least 2 comorbidities, 3 patients had 3, 2 patients had 2, and 2 patients had 6. Eight (57%) of 14 had post-operative complications including: Symptomatic hardware + removal (6), revision surgery (4), and compartment syndrome (1). Five patients retained their broken screw without complication. Conclusion: Patients with syndesmosis screw breakage are a highly comorbid population. Patients in this study, on average, had a significantly elevated BMI potentially predisposing them to screw failure. In conclusion, future analysis of syndesmosis injuries should include BMI and comorbidities. Future studies should pay special attention to BMI as potential confounding variable when attempting to determine reasons for syndesmosis screw breakage. [Table: see text]
Cost Comparison of Suture Anchor Modified Broström Repair and Augmentation of the Modified Broström with FiberTape Device
Authors: Vannatta Emily , Stauch Chris M. , King Jesse , Kim Morgan S. , Luick Laura R. , Bifano Shawn M. , Juliano Paul J. , Aydogan Umur , Aynardi Michael C. 
Published: November 2020

Category: Ankle; Sports Introduction/Purpose: Augmentation of the Broström procedure with FiberTape device has been described for the treatment of chronic ankle instability. However, it has yet to be determined if the cost of the implant is negated by the benefits to the patient. The purpose of this study was to perform a comprehensive cost analysis by comparing the cost of surgical procedure, physical therapy visits, time off work, and any costs related to revision surgery between the Broström reconstruction with suture anchors alone versus augmentation with a FiberTape device. Methods: 166 patients undergoing lateral ankle ligament repair were analyzed retrospectively. Patients underwent either a modified Broström ligament repair with two suture anchors or Broström ligament repair with FiberTape augmentation. All patients followed the same post-operative protocol for early weight bearing and initiation of physical therapy once the wound was healed. Timing of return to work and the total number of visits of physical therapy before discharge were recorded. Implant costs, facility charges and professional fees were obtained from billing records. Lost income for missed days of work was based on the Pennsylvania Bureau of Labor Statistics. Complications requiring return to the operating room were recorded. Patients were followed out to one year. Results: Aggregate cost in the modified Broström group was $2,219 more expensive than when augmenting with FiberTape ($20,970 vs. $18,751) despite an increased implant cost of $900. This difference was the result of a greater number of therapy visits and days out of work in the modified Broström group versus the augmentation group (14.9 vs 12.4) as well as a significantly higher amount of days out of work in the modified Broström group versus augmentation (63.3 vs. 53.8 days respectively). No statistically significant difference was found for operation time between groups, and failure rates were similar; 2.0% (1/49) for FiberTape and 3.4% (4/117) for modified Broström. Conclusion: The aim of this study was to explore the cost comparison of the modified Broström procedure for chronic ankle instability versus the FiberTape augmentation. Despite an upfront increase in implant costs, the average cost per procedure was lower for the augmentation group. The majority of cost savings occurred in decreases in the number of physical therapy visits and faster return to work times. The results of this study suggest that the use of FiberTape to augment modified Broström repair may have a financial benefit and cost savings to patients and the healthcare system.