bluuebunny/crossref_metadata_2025_split huggingface dataset:
Independent Inter- and Intra-Rater Reliability of the New AO and Leonetti/Tigani Systems for Pilon Fractures based on CT-Scan
Authors: Guiloff Benjamin , Villa Andres , Ananias Joaquin , Mery Pablo , Ledermann Gerardo , Correa Ignacio , Palma Joaquin 
Published: November 2020

Category: Basic Sciences/Biologics; Trauma Introduction/Purpose: There is still no consensus regarding which is the best classification system for the management of tibial plafond fractures. The goal of this study is to perform a independent agreement evaluation to compare two recently published systems: Leonetti/Tigani and the new AO classification. Methods: Seventy-five patients with tibial plafond fracture and preoperative CT scan were included. Six raters with different level of expertise (two foot and ankle surgeons and three orthopedic surgery residents) classified the fractures using CT scans according to the morphological grading of both systems. The Leonetti/Tigani classification system considers four types (I, II, III and IV) and six subtypes (I, IIF, IIS, IIIF, IIIS, IV). The AO system considers three types (A, B, C) and nine subtypes (A1, A2, A3, B1, B2, B3, C1, C2, C3). After six weeks all cases were randomly re-evaluated by the same raters. The kappa coefficient (κ) was used to determine the degree of reliability. Results: Inter-observer reliability: strong using the Leonetti/Tigani classification system considering types, with a κ of 0,65 (0,60 - 0,69), and subtypes, with a κ of 0,62 (0,58 - 0,66). Reliability for the AO system was strong considering types with a κ of 0,72 (0,66 - 0,78), but moderate when including subtypes with a κ of 0,54 (0,50 - 0,57). Intra-rater reliability: Almost perfect using the Leonetti/Tigani classification considering both types and subtypes with a κ of 0,94 (0,88- 1,01) and 0,94 (0,89- 0,96), respectively. Reliability for the AO system was almost perfect considering types with a κ of 0,83 (0,75- 0,92), but strong when including subtypes with a κ of 0,61 (0,57- 0,66). No statistically significant difference between different levels of expertise. Conclusion: The system proposed by Leonetti/Tigani demonstrated a strong and almost perfect inter and intra-rater reliability, respectively. Although the new AO classification has a strong inter-rater reliability when including the main categories, it only reached a moderate reliability when including subtypes.
Biomechanical Results of Percutaneous Calcaneal Osteotomy using Two Different Osteotomy Designs
Authors: Gutteck Natalia 
Published: November 2020

Category: Hindfoot Introduction/Purpose: Percutaneous osteotomy of calcaneus has been proposed to reduce the complication rate and became more and more popular. The bone cut can be performed as a straight or chevron-like (V) osteotomy using a Shannon burr. Comparative studies of straight or V- osteotomy as like as one or two screws in percutaneous calcaneal osteotomies are missing in the literature Methods: The straight osteotomy (9 fresh-frozen specimens) and V- osteotomy (9fresh frozen specimens) was performed and the calcaneal tuberosity was moved 10 mm medially and slightly rotated. One 6,5 mm cancellous compression screw was used for osteosynthesis. Specimens were preconditioned with 100N over 100 cycles. The force was increased after every 100N by 100N from 200 to 500N. This was followed by cyclic loading with 600N for 500 cycles. Results: Despite the higher mean values of the group with V osteotomy, no significant difference was registered between the two groups regarding the stiffness at all force levels. A significant higher failure rate was observed in the group with straight osteotomy. Conclusion: The moderate correlation of bone density and stiffness in the V-group, and significantly lower failure rate with no secondary dislocation in fluoroscopy indicates the superiority of the V-osteotomy in the present study. Whether the demonstrated advantages can be reflected in clinical practice should be investigated in further studies.
Comparative Results of Percutaneous Calcaneal Osteotomy in Correction of Hindfoot Deformities
Authors: Gutteck Natalia 
Published: November 2020

Category: Hindfoot Introduction/Purpose: Calcaneal osteotomies are often required in correction of hindfoot deformities. The traditional open techniques as lateral or oblique incision are occasionally associated with wound healing problems and neurovascular injury. Methods: In a prospective study 122 consecutive patients who underwent a calcaneal osteotomy for hindfoot realignment treatment were included. 58 patients were operated using an open incision technique and 64 patients with 66 feet using a percutaneous technique. Clinical and radiological assessments were performed preoperatively, six weeks and one year postoperatively. Results: The AOFAS score and VAS improved in both groups postoperatively. The difference was not significant. The results of the radiological measurements pre- and postoperatively were not significantly different. No pseudarthrosis occurred in both groups. The comparison of both groups showed a significant lesser risk for wound healing problems in percutaneous group (B). The hospitalisation time was significantly shorter in the percutaneous group. Conclusion: Due to the excellent results with the percutaneous calcaneal osteotomy the authors feel encouraged to establish this procedure as a standard technique for calcaneus osteotomy at our clinic.
Trends in Total Ankle Replacement in Scotland
Authors: Ha Taegyeong T. , Senthil Kumar Chinnasamy , Ha Taegyeong T. , Higgs Zoe , Watling Chris , Osam Cemre Su. , Madeley N. Jane , Halai Mansur 
Published: November 2020

Category: Ankle Arthritis Introduction/Purpose: Total ankle replacement (TAR) is performed for post-traumatic arthritis, inflammatory arthropathy, osteoarthritis and other indications. The Scottish Arthroplasty Project (SAP) began collection of data on TAR in 1997. In this study, using data from the SAP, we look at trends in the use and outcomes of TAR in Scotland. Methods: We identified 499 patients from the SAP who underwent TAR between 1997 and 2015 with imaging available on the National Picture Archiving and Communication System (PACS). We identified, and looked at trends in, implant type over the following time periods: 1998-2005; 2006-2010 and 2011-2015. Age, gender, indication and outcomes for each time period were examined and also trends with implant type over time. Results: There were 499 primary TAR procedures with an overall incidence of 0.5/105 population per year. The peak incidence of TAR was in the 6th decade. The mean age of patients undergoing TAR from 59 years in 1998-2005, to 65 years in 2011-15 (p<0.0001). The percentage of patients with inflammatory arthropathy was 49% in 1998-2005, compared with 10% in 2011-2015. Subsequent arthrodesis and infection rates appeared to be higher during the first time period. The female to male ratio also changed over time. The incidence of TAR increased overall during the study period (r= 0.9, p=<0.0001). This may be due to a broadening range of indications and patient selection criteria, in turn due to increased surgeon experience and the evolution of implant design. Conclusion: This study examines a large number of TARs from an established national arthroplasty database. The rate of TAR has increased significantly in Scotland from 1997 to 2015. Indication and patient age has changed over time and this could potentially impact outcomes after ankle replacement.
3D Imaging for Hindfoot Alignment: A Comparative Study between MRI and Weight Bearing CT
Authors: Haldar Anil , Bernasconi Alessio , Junaid Syed E. , Welck Matthew J. , Saifuddin Asif 
Published: November 2020

Category: Hindfoot; Other Introduction/Purpose: Hindfoot malalignment is a common finding in multiple foot and ankle pathologies. In clinical practice, it is usually quantified through traditional weight bearing radiographs or, more recently, through cone beam weight bearing CT (CB- WBCT), which overcomes issues related to two-dimensional imaging. Interestingly, a few studies have suggested that hindfoot alignment can also be accurately assessed using non-weight bearing magnetic resonance imaging (MRI). The purpose of this study was to compare measurements of hindfoot alignment on non-weight bearing ankle MRI and CB-WBCT and to establish if there was any correlation. Methods: In this Level III retrospective comparative study, a database review identified 51 feet in 47 patients (27 males, 20 females; mean age of 45 (range 13-79)) which had both CB-WBCT and MRI scans on the same day as part of standard care at our specialist tertiary referral Foot and Ankle Unit. Hindfoot alignment was assessed by independent Consultant Musculoskeletal specialists. The foot ankle offset (FAO), calcaneal offset (CO) and hindfoot alignment angle (HA) were assessed on CB-WBCT using dedicated software. The tibiocalcaneal angle (TCA) and calcaneofibular ligament angle (CFLA) were assessed on non-weight bearing MRI. Pearson correlation was used to evaluate the correlation between these measurements. Results: We found a statistically significant positive correlation between TCA on non-weight bearing MRI and each measurement on CB-WBCT (Pearson correlation for TCA and FAO: 0.42, p=0.003; for TCA and CO: 0.46, p=0.001; and for TCA and HA: 0.40, p=0.005).We also demonstrated a moderate-to-low negative but significant correlation between CFLA and CO (Pearson correlation: -0.35; p=0.03). Conversely, the negative correlation between CFL and FAO (Pearson correlation: -0.29; p=0.07) and CFL with HA (Pearson correlation: -0.26; p=0.11) did not reach statistical significance. Conclusion: Weight bearing three-dimensional imaging has shown high degrees of accuracy and reproducibility for hindfoot alignment. The significant correlation between TCA on non-weight bearing MRI and hindfoot alignment measurements on CB- WBCT suggests that TCA should be reported during routine ankle MRI in order to put into context some of the soft-tissue findings. The CFLA shows a less significant negative correlation.
Do We Really Need to Worry About Calcaneocuboid Subluxation During Lateral Column Lengthening for Planovalgus Foot Deformity?
Authors: Hedrick Brittany , Riccio Anthony , Siebert Matthew , Shivers Claire , Harris Mitchell , Pierce William A. , Thomas Danielle M. , Zide Jacob R. 
Published: November 2020

Category: Midfoot/Forefoot; Other Introduction/Purpose: While lengthening of the lateral column through a calcaneal neck osteotomy is an integral component of flatfoot reconstruction in younger patients with flexible planovalgus deformities, the procedure has been implicated in iatrogenic calcaneocuboid (CC) subluxation and subsequent degenerative changes at the CC articulation. The purpose of this study is to characterize alterations at the CC joint following lateral column lengthening (LCL) as well as to determine if Steinman pin stabilization of the CC joint prior to distraction maintains a normal CC relationship. Methods: Seven matched pairs of fresh frozen cadaveric feet underwent pre-procedure plain radiography and cross-sectional computed tomography (CT) imaging. LCL via a calcaneal neck osteotomy was then performed. One foot of each matched pair had a single smooth Steinman pin placed centrally across the CC joint prior to osteotomy distraction. Distraction across each osteotomy was then performed and maintained with a 12mm porous titanium wedge. Repeat imaging was obtained and compared to pre-procedure studies to quantify sagittal and rotational differences at the CC articulation Results: Following LCL, plain radiography demonstrated statistically significant increases in the percentage of the calcaneal articular surface dorsal to the superior aspect of the cuboid in both the pinned (8.2% vs 17.6%, p=0.02) and unpinned (12.5% vs 16.3%, p=0.04) specimens. No difference in the percentage of subluxation was found between the two groups following LCL. CT imaging demonstrated statistically significant increases in rotation between the calcaneus and cuboid following LCL in both the pinned (7.6O +- 5.6O, p=0.01) and unpinned (17O +- 12.3O, p=0.01) specimens. Though a greater degree of rotation was present in the unpinned specimens following LCL, this difference was not statistically significant (p=0.28). Conclusion: Both sagittal and rotatory subluxation seem to occur at the CC joint following LCL regardless of pin stabilization. As a single pin would be expected to limit pure translation while having little effect on rotation, it is possible that the rotational changes identified on three-dimensional imaging are interpreted as dorsal translation when viewed two dimensionally using plain radiography. Consideration should therefore be given to CC stabilization with two pins during LCL to prevent this rotatory subluxation.
Epidemiology of Lateral Ankle Ligament Injury: Trends in Clinical Management and Likelihood of Progression to Surgical Intervention
Authors: Hermanns Christina , Coda Reed , Messamore William G. , Vopat Matthew , Morris Brandon L. , Cheema Sana , Tarakemeh Armin , Schroeppel Paul , Mullen Scott , Vopat Bryan G. 
Published: November 2020

Category: Ankle Introduction/Purpose: Lateral ankle ligament sprains occur frequently in both general and athletic populations. Most patients recover from their injury without complication, however, some experience persistent pain and instability following lateral ankle injury, which requires treatment with surgical stabilization. The purpose of this study is to determine the utilization and associated costs of non-operative treatment modalities, such as physical therapy (PT), non-steroidal anti-inflammatory medication, and ankle bracing, as well the incidence of lateral ankle sprains that receive surgical treatment and the costs incurred by surgical treatment of chronic lateral ankle instability. Methods: Data was collected using the Pearl Diver Humana dataset using ICD-9, ICD-10, and CPT codes pertaining to ankle sprain, ankle ligament repair or reconstruction, physical therapy, ankle brace ordering, and non-steroidal anti-inflammatory medication (NSAID) ordering. Patients diagnosed with an ankle sprain were sub-divided into three categories: non-operative treatment, surgical ligament repair, and surgical ligament reconstruction. Incidence, cost, and PT usage was compared between patient groups. Cost analysis was performed per group using associated ICD/CPT cost and physical therapy cost. NSAID use and ankle bracing use was also examined. Results: Of patients who sustained lateral ankle injury, 64% were female and 36% were male. 306,180 (98.8%) patients successfully completed non-operative management. 2,774 (1.2%) patients underwent surgical intervention. 63,276 (20.7%) non- operative patients received physical therapy, whereas 1,536 (55.4%) surgically treated patients received PT after surgery. Only 725 (26.1%) surgical patients received pre-operative PT. Median time for total PT treatment of surgical patients was 21.8 weeks, while non-operative patients received treatment for a median time of 58.7 weeks. On average non-operative patients generated 11 billed days in PT while surgical patients received 8 days of PT before surgery and 11 days in PT after surgery. Average total cost per patient was $923.32 for non-operative patients, $3,384.63 for surgical ligament repair, and $3,659.98 for surgical ligament reconstruction. Conclusion: The vast majority of patients with lateral ankle ligament sprains do not progress to surgical treatment. Patients treated non-operatively used fewer physical therapy visits per patient and generated less cost compared to surgically treated patients. Only 20% of non-operative patients received physical therapy. Additionally, a higher proportion of surgically treated patients participated in PT compared to patients treated non-operatively.
Review of Variability in Rehabilitation Protocols after Lateral Ankle Ligament Surgery
Authors: Hermanns Christina , Coda Reed , Cheema Sana , Vopat Matthew , Bechtold Megan , Tarakemeh Armin , Mullen Scott , Schroeppel Paul , Vopat Bryan G. 
Published: November 2020

Category: Ankle; Sports Introduction/Purpose: Ankle sprains are one of the most common athletic injuries. If a patient fails to improve through conservative management, surgery is an option to restore ankle stability. The purpose of this study is to analyze the variability across rehabilitation for patients undergoing lateral ankle ligament repair, reconstruction, or suture tape augmentation. Methods: 26 protocols were found. Inclusion criteria was protocols for ankle ligament surgery. Protocols for nonoperative care were excluded. A rubric was created to analyze weightbearing, range of motion (ROM), immobilization, single leg exercises, return to running, and return to sport (RTS). Results: There was variability especially in recommendations for immobilizing brace, partial and full weigh bearing, specific ROM movements of the ankle, and return to single leg exercise and running. For repair and reconstruction, none of these categories had greater than 60% agreement. 100% (12/12) of repair and 86% (12/14) of reconstruction protocols recommended no ROM postoperatively, and 86% (6/7) repair and 78% (11/14) reconstruction recommended no weightbearing postoperatively, making postoperative ROM and weightbearing status the most consistent aspects across protocols. Suture tape augmentation protocols generally allowed rehabilitation on a quicker timeline with full weightbearing by week 4-6 in 100% (3/3) of protocols and full ROM by week 8-10 in 66% (2/3). RTS was consistent in repair protocols (100% at week 12-16). Conclusion: ROM was variable across protocols and did not always match up with supporting literature. Return to sport was likely to correlate between protocols and the literature. Weightbearing was consistent between protocols. The variability between programs demonstrated the need for standardization of rehabilitation.
Incidence and Trends in Lower Extremity Amputations in the United States
Authors: Herzog Leah , Johnson Charles , Gross Christopher E. 
Published: November 2020

Category: Trauma Introduction/Purpose: Currently there is minimal focus on traumatic lower extremity amputations due to their relatively low incidence, but they often come with a higher morbidity and mortality than its upper extremity counterparts. The purpose of this study was to evaluate the incidence and trends of lower extremity amputations in the United States over a ten-year period. Methods: The National Electronic Injury Surveillance System (NEISS), was used for evaluation of lower extremity amputations that presented to the United States emergency departments. The overall incidence rate of lower extremity amputations within the United States was calculated as per 100,000 persons. After grouping mechanisms of injury, the data were stratified by both age groups and gender. Chi-square tests were used for direct comparisons of proportions. The five most common mechanisms were ranked for each age group and the most common overall age group for lower extremity amputations were determined using descriptive statistics. Trends for injury incidence and hospital admissions were evaluated using linear regression and Pearson correlation with Bonferroni correction. Results: From 2008 to 2017, 393 patients were reported to have sustained lower extremity amputations via the NIESS database with an estimated 11,475 patients sustaining a lower extremity amputation over the past ten years and an incidence of 2.2/100,000 person-years. The incidence of lower extremity amputations is highest in those less than five years old. Lawnmower incidents are the most common mechanism of injury in all age groups. Conclusion: Due to the high morbidity and mortality associated with these injuries, it is prudent to follow the trends in lower extremity amputations.
Is there a Difference in Outcomes between Patients who Received a Double or Triple Arthrodesis for Hindfoot Arthritis?
Authors: Holleran Amanda H. , Baumhauer Judith F. , Houck Jeff , Homeier Daniel , Flemister Adolph S. , Ketz John P. , DiGiovanni Benedict F. , Oh Irvin 
Published: November 2020

Category: Hindfoot Introduction/Purpose: Triple arthrodesis has historically been considered the standard of treatment for arthritis of the hindfoot with or without deformity. The complications of this surgery including non-union, malunion, nerve injury, infection and wound healing problems can occur at any of the three joints. Double arthrodesis is capable of producing a similar reduction in degrees of motion and correction of foot deformity but may also cause less patient morbidity in regard to these complications due to one less joint being incorporated into the fusion procedure. What is unknown is the patient reported outcomes, specifically physical function (PF) and pain interference (PI) between these two procedures. The purpose of this study is to evaluate the clinical outcomes for hindfoot deformity using a triple compared to a double arthrodesis. Methods: A retrospective medical record review was performed (February 2015-December 2019), of 96 identified cases, 54 had complete data over 4 months post operation for either a double (Age = 58 (11); Body Mass Index (BMI) = 34.4 (6.0); n=24) or triple arthrodesis (Age= 55 (13); BMI = 33.0 (10.0); n = 30). Patient Reported Outcome Measurement Information System (PROMIS) physical function and pain interference were assessed at last available pre-operation and last follow up time points. Medical records were reviewed for complications (yes/no). ANOVA models were used to assess differences pre to post surgery (covariates included age, BMI, and length of follow up). Chi Square analysis was used to assess proportions of patients achieving a minimal clinically important difference (34.5) and complications by group. Results: There were no differences between groups in terms of age (p = 0.51), BMI (p = 0.44), or length of follow up (triple = 540 (334) days versus double = 390 (336) days; p=0.12). There were no significant differences in PROMIS PF (pre-post change 95% CI: triple= 1.2 (-4.1 to 1.6) versus double = 0.2 (-2.5 to 2.0)). The for PROMIS PI both groups experienced lower pain (average 5.1 (1.0) with the greater decrease in pain in the triple group (Figure 1; pre-post change 95% CI: triple= 7.1 (-10.2 to -4.0) versus double = 3 (-5.5 to -0.6)). Chi square analysis showed that a greater proportion of patients undergoing a triple (triple 61.9 % versus double 33.3 %) experienced MCID improvement in PROMIS PI (X2=4.4, p=0.04). There were 4 complications in the double group, and 6 in the triple group. Conclusion: Double arthrodesis can allow for similar correction of foot deformities without the increased risk of wound complication, infection or nonunion/malunion. However, we found that patients who underwent a triple arthrodesis were more likely to have an improvement in minimally important clinical difference (MCID) in the PROMIS pain interference scores than those who underwent a double arthrodesis.