bluuebunny/crossref_metadata_2025_split huggingface dataset:
Effectiveness of the Saline Load Test in Diagnosis of Traumatic Ankle Arthrotomies in Varying Arthrotomy Locations
Authors: Ohliger Erin , Miniaci-Coxhead Sara Lyn 
Published: October 2019

Category: Ankle, Trauma Introduction/Purpose: The purpose of this study was to investigate the amount of fluid required and the sensitivity of the saline load test to identify an intra-articular arthrotomy of the ankle. Limited prior studies have been conducted in arthroscopic models with proposed volumes ranging from 30 ml to 60 ml. Due to this range it was inferred that volume needed to detect arthrotomy would vary based on site of arthrotomy. Using cadavers without prior ankle trauma or surgeries we aim to assess volume needed to detect ankle arthrotomies at varying arthrotomy locations. Methods: A cadaveric study was conducted using 20 thawed, fresh-frozen below knee amputations. Cadavers were randomly divided into four groups of five and an ankle arthrotomy was made using a 4 mm trochar at standard ankle portal sites; anteromedial, anterolateral, posteromedial, and posterolateral. To confirm intra-articular location, a scope was inserted for direct visualization. A 18-gauge needle was then inserted into the anteromedial portal, except for the anteromedial arthrotomy where the needle was inserted into the anterolateral portal, and saline mixed with methylene blue was loaded into joint. During the injection, the known arthrotomy site was viewed for extravasation. Amount of saline required to diagnose arthrotomy was recorded. All injections were confirmed as intra-articular by demonstrating methylene blue staining of the anterior joint by open exploration. Results: The saline volume required to achieve extravasation ranged from 3 mL to 11 mL. The median saline volume required to achieve extravasation was 5.3 mL. A total of 8 mL was required to achieve 90% sensitivity, 10 mL for 95% sensitivity and 11 mL for 99% sensitivity. For the anterolateral, anteromedial, posteromedial, and posterolateral arthrotomy sites the median saline volume needed to detect a traumatic arthrotomy was 5.2 ml, 6.2 ml, 5 ml, and 4.8 ml respectively. There was no statistically significant difference in volume needed to detect arthrotomies across all four locations. Conclusion: A minimum injection of 10 mL is recommended to identify 95% of traumatic arthrotomies approximately 4 mm in size. Prior studies performed in arthroscopic models with prior ankle pathology may overestimate volume needed to detect arthrotomies. No difference in volume needed to detect extravasation was found across all four arthrotomy locations.
Tibiotalar Joint Contact Mechanics Following Syndesmosis Fixation with Screws Versus a Flexible Fixation Device (TightRope™)
Authors: Pang Eric , Bedigrew Katherine , Behn Anthony , Chou Loretta , Hunt Kenneth , Palanca Ariel 
Published: October 2019

Category: Ankle, Arthroscopy, Trauma Introduction/Purpose: Background: A shift and increase in mean tibiotalar contact pressure has been demonstrated in simulated syndesmotic injuries. The effect of screw fixation and/or suspensory fixation on restoration of pressure mechanics in the setting of a syndesmotic injury remains largely unknown. Hypothesis/Purpose: The purpose of this study is to examine the contact mechanics of the tibiotalar joint following syndesmosis fixation with screws versus a flexible fixation device for complete syndesmotic injury. Methods: Six matched pairs of cadaveric below knee specimens were randomly assigned fixation with either two 3.5 mm cortical screws or two TightRopes™ (Arthrex). Motion capture trackers were fixed to the tibia, fibula, and talus and a pressure sensor was placed in the tibiotalar joint. Each specimen was first tested intact with an axial compressive load followed by external rotation torque while maintaining axial compression. The syndesmosic ligaments were then completely sectioned and subsequently repaired with either two TightRopes™ or two screws and the protocol was repeated. Mean contact pressure (MCP), peak pressure (PP), reduction in contact area (CA), translation of the center of pressure (COP), and relative talar and fibular motion were calculated. Specimens were then cyclically loaded in external rotation to failure. Comparisons were made using paired t-tests and/or Welch’s t-tests. Results: No differences in MCP, PP, or CA were observed between the intact and instrumented states during AL alone for either group. MCP relative to intact testing was increased in the screw group at 5 Nm (4.8±4.1 MPa vs 3.6±0.8 MPa, p=0.033) and 7.5 Nm torque (6.2±1.4 MPa vs 4.2±1.2 MPa, p=0.024). Likewise, PP was increased in TightRope™ group at 7.5 Nm torque (14.4±3.1 MPa vs 10.8±1.6 MPa, p=0.046). There was no change in COP in the TightRope™ group at any threshold; however, at every threshold tested there was significant medial and anterior COP translation in the screw group relative to the intact state. Conclusion: Either screws or TightRope™ fixation is adequate with AL alone. With lower amounts of torque, the TightRope™ group exhibits contact and pressure mechanics that more closely match native mechanics.
A Suspicious Atypical Fracture of 5th Metatarsal Bone: A Case Report
Authors: Park Byeong-Seop , Koo Seungbum , Park Won-keun , Kwon Ki-bum , Lee Kyoung Min 
Published: October 2019

Category: Trauma Introduction/Purpose: Long-term usage of bisphosphonate can severely suppress bone turnover and alter bone mechanical properties, thereby resulting in atypical fractures that mainly occur at the femur.We present a rare case of suspicious atypical fracture of the metatarsal bone. Methods: A 63-year-old woman presented to our clinic with a primary complain of a one-week history of pain in her right foot. The patient had no history of trauma to the right foot and denied any strenuous activity. She experienced lateral foot pain while walking within her home. She was on alendronate therapy for osteoporosis for a decade. X ray and CT examination revealed a fifth metatarsal fracture whose features were compatible with those of atypical femoral fractures (Figure 1). Results: The patient was advised to discontinue alendronate and underwent percutaneous surgical fixation of the fracture via a proximal approach using a 4.0-mm half-threaded cannulated screw. Postoperatively, a short leg cast was created and the patients performed non-weight bearing ambulation until the cast was removed at the sixth postoperative week. Radiography in the sixth postoperative week revealed callus formation. Conclusion: Our findings suggest that physicians must keep in mind that atypical fractures could possibly occur at bones other than the femur.
Opposite Association Between Radiographic Lateral Ankle Instability and Osteochondral Lesions of the Talus in Patients with Ankle Inversion Injuries
Authors: Park Byeong-Seop , Koo Seungbum , Park Won-keun , Kwon Ki-bum , Lee Kyoung Min 
Published: October 2019

Category: Ankle Introduction/Purpose: Insufficient bony coverage surrounding the talus could cause considerable mechanical ankle instability, whereas excessive bony coverage could cause bone contusion at the time of injury and subsequent osteochondral lesions of the talus (OLT). This study aimed to investigate the relationship between radiographic lateral ankle instability and OLT in patients that sustained ankle inversion injuries. Methods: One-hundred-ninety-five patients (113 men and 83 women; mean age, 38.7 years; standard deviation, 8.8 years) with a history of ankle inversion injuries were included. All patients underwent ankle magnetic resonance imaging (MRI) and stress X-ray (varus stress and anterior drawer) examination. The tibiotalar tilt angle on varus stress X-ray, anterior translation of the talus on anterior-drawer lateral X-rays, bimalleolar tilt angle, and fibular position were radiographically determined. The anatomical grade of the lateral ankle ligament injury and the presence of OLTs were determined from MRI findings. Results: A greater lateral ankle ligament grade tends to increase the tibiotalar tilt angle (p=0.074), significantly affecting the anterior translation of the talus (p=0.036). The presence of radiographic lateral ankle instability (tibiotalar tilt angle =10°) showed opposite associations with the presence of OLT in the chi-square test (p=0.003). OLT was a negative significant factor (p=0.011) affecting the tibiotalar tilt angle in the multiple regression analysis (Table 1) and was negatively affected by the tibiotalar tilt angle (p=0.016) in the binary logistic regression analysis. Conclusion: This study showed an opposite association between lateral ankle instability and the development of OLT following ankle inversion injury. The role of bony predisposition in the development of sports injuries in the ankle should be considered and investigated further.
The Assessment of Reduction Status Using Radiographic Parameters and Ideal Trans-Fixation Technique for Unstable Syndesmotic Injury with Ankle Fracture
Authors: Park Chul-Hyun , Song Kwang-Soon , Kim Beom-Soo , Choi Jung-Hoon , Kwon Hyuk-Jun , Hee Son-Young 
Published: October 2019

Category: Ankle, Trauma Introduction/Purpose: Anatomical restoration of distal tibiofibular syndesmosis is essential in ankle fractures with syndesmotic injury. However, intraoperative reference line of penetrating angle and evaluation of reduction status remains without consensus. The purpose of this study is to analyze the reduction status of syndesmotic injury using radiographic parameters and to find ideal fixation angle treated with trans-fixation in unstable syndesmotic injury. Methods: Twenty-six patients with ankle fractures with syndesmotic injury that underwent preoperative and postoperative bilateral computed tomography (CT) scans were enrolled. A multi-center study was performed in two tertiary medical centers. All patients were treated with tibiofibular trans-fixation screw or tight rope® fixation. The axial sections of bilateral CT scans were reviewed to measure Fibular Diastasis (FD) and Surface Area of Syndesmosis (SAS) at the level of 1.0 cm above ankle joint. Reduction status was measured by calculating the ratio of postoperative and intact side using radiologic parameters. The trans-fixation angles between the perpendicular line of incisura and distal trans-fixation material was measured. Patients were classified by trans-fixation angle into three groups, as showing 0 -1 degree (A), 1-5 degree (B), 5 or more degree (C) in absolute value. Results: The mean value of reduction status ratio was 1.13 in FD and 1.27 in SAS. The absolute mean value of trans-fixation angle was 4.11°. Trans-fixation angle and reduction status had positive correlation in FD (R = 0.522, p = 0.006) and SAS ratio (R = 0.695, p = 0.000). The absolute mean value of trans-fixation angle in group A, B, C was 0.56° (7 cases), 3.01° (12 cases), and 8.90° (7 cases). The mean value of FD ratio in group A, B, C was 1.01, 1.03 and 1.41. FD and SAS ratio had no difference between group A and B but had significant difference between group A, B and C (p < 0.05). Conclusion: Inappropriate trans-fixation technique had correlated with the loss of reduction after treatment of unstable ankle fracture associated with syndesmotic injury. An angle of 5° from the perpendicular line of the incisura is considered as the ideal trans-fixation angle to maintain the reduction status.
Survivorship and Long-term Results of Consecutive Series of 118 Hintegra Total Ankle Arthroplasties
Authors: Park Jae Han , Hwang Yeok Gu , Kwon Jae Bum , Shim Dong Woo , Park Kwang Hwan , Han Seung Hwan , Lee Jin Woo 
Published: October 2019

Category: Ankle Arthritis Introduction/Purpose: Total ankle arthroplasty (TAA) has been more suggested to patients with end-stage ankle osteoarthritis. However, there were few studies which had investigated long-term clinical outcomes with mobile bearing system. The purpose of this study is to evaluate the long-term outcomes of total ankle arthroplasty with use of the Hintegra prosthesis and to identify prognostic factors that affect the outcome. Methods: Between September 2004 and December 2009, 118 ankles underwent total ankle arthroplasty with Hintegra prosthesis. Clinical outcomes were assessed annually after operation using visual analog scale (VAS), American Orthopaedic Foot & Ankle Society (AOFAS) scores, plain radiographs and re-operation. Kaplan-Meier survival plot showed survival outcomes of TAA in long-term follow-up. Results: The mean follow-up period was 10.9 years (range 9.0-14.3). The mean change from baseline to final follow-up was -6.7 ± 4.3 points for VAS, and 26.1 ± 10.3 points for the AOFAS score. Three (2.5%) of the ankles required metal component revision at a mean of 2.9 ± 1.8 years (range, 0.5 to 5.8 years) after primary surgery. Five (4.2%) ankles underwent conversion to arthrodesis. Cystic osteolysis that needed surgery was 19 (16.1%) cases, most frequent lesion was posterior aspect of distal tibia. 65 ankles (55.1%) showed heterotopic ossifications but the degree of heterotopic ossification was not significantly correlated with VAS and AOFAS score. Revision with metal component as the end point of prosthesis was 86% at 10 years of follow up. Conclusion: Long term outcomes were satisfactory after mobile-bearing total ankle arthroplasty. Further study to elucidate possible reasons for osteolysis and subjective pain after TAA is warranted.
Increasing Values of the Lateral Talar-First Metatarsal Angle Preoperatively Predict Spring Ligament Attenuation in Adult Acquired Flat Foot Deformity
Authors: Pate Matthew , Hall Jacob , Albright Patrick , Bohay Donald , Anderson John , Roberts Justin 
Published: October 2019

Category: Ankle, Hindfoot, Trauma Introduction/Purpose: Adult acquired flat foot deformity (AAFD) is responsible for numerous adult foot and ankle deformities, and spring ligament damage has been implicated in the pathology of AAFD. Treatment of AAFD may involve attempts to address spring ligament incompetency, and preoperative knowledge of spring ligament integrity would be valuable in planning for such procedures. To our knowledge, there have been no attempts to correlate preoperative radiographs with direct intraoperative evaluation of spring ligament competency. This study aims to examine the relationship between preoperative radiographic measures specific to flatfoot deformity and intraoperative competency of the spring ligament during flatfoot reconstruction in order to find radiographic measures predicting spring ligament attenuation. Methods: The operative reports of 3 fellowship trained orthopaedic foot and ankle surgeons were searched over a 5-year period from 2012-2017. Patients with pre-operative standing AP and lateral radiographs along with an operative report directly visualizing and commenting on spring ligament integrity were included in the study. Investigators reviewed operative reports to identify patients with spring ligament tears and evaluated pre-operative radiographs. Five common radiographic parameters were measured: lateral talar-first metatarsal angle, AP talar-first metatarsal angle, talonavicular coverage angle, talonavicular coverage percentage, and calcaneal pitch. Chi-square and logistic regression analysis were used to evaluate the five radiographic parameters for association with spring ligament tear. Results: The study enrolled 58 patients with 29 patients having confirmed spring ligament tears and 29 patients having an intact spring ligament. Increasing values for each of the 5 radiographic measures were statistically significant predictors for spring ligament tear on univariate analysis (p=0.001) with the lateral talar-first metatarsal angle being the most significant predictor for spring ligament tear (p<0.001). On logistic regression analaysis, LT-1st angle was a significant predictor of spring ligament tear (p<0.001). A lateral talar-first metatarsal angle =30 degrees had a sensitivity and specificity of 65% and 100% for spring ligament attenuation. The positive predictive value of spring ligament tear with a lateral talar-first metatarsal angle =30 degrees was 100% and the negative predictive value was 74%. Conclusion: This study is the first to correlate preoperative radiographs with direct visualization and evaluation of spring ligament competency. Increasing severity of common radiographic measures of flat foot deformity, particularly the lateral talar-first metatarsal angle, correlate significantly with spring ligament tear and may assist surgeons in planning appropriate preoperative interventions.
Radiographic Outcomes of Plate vs Screw Constructs in Open Reduction and Internal Fixation of Calcaneus Fractures via the Sinus Tarsi Approach
Authors: Pitts Charles , Almaguer Adam , Wilson Jack , Johnson Michael 
Published: October 2019

Category: Hindfoot, Trauma Introduction/Purpose: Intra-articular fractures of the calcaneus are a common injury to the hindfoot following high energy trauma to the lower extremity. Treatment of these fractures has evolved. Due to the concern of wound complications associated with extensile open treatments, smaller incision techniques, such as the sinus tarsi approach, are increasing in popularity. A number of fixation strategies are utilized with this approach, and it is unknown which most accurately restores radiographic alignment. The purpose of this study is to compare the postoperative radiographic outcomes of a plate and screw construct versus a cannulated screw construct when using the sinus tarsi approach for open reduction and internal fixation (ORIF) of calcaneus fractures. Methods: After IRB approval, records for all patients treated surgically at our institution for calcaneus fractures from 2012 to 2017 were reviewed. Inclusion criteria were intra-articular calcaneus fractures, patients aged 18 years or older, and use of the sinus tarsi approach. Exclusion criteria were open fractures and clinical follow up less than 6 weeks. A total of 51 fractures underwent ORIF using cannulated screws alone (Group 1), and 23 fractures underwent ORIF using a sinus tarsi plate (Group 2). The primary outcomes of interest included pre- and postoperative Bohler and Gissane angles, wound complications, and unplanned return to OR. Results: There was no statistically significant difference between preoperative Bohler angles for Group 1 (14.5 degrees) versus Group 2 (12.3 degrees) (p=0.35), nor was there a significant difference between postoperative Bohler angles between Group 1 (30.1 degrees) and Group 2 (27.0 degrees) (p=0.09). Similarly, preoperative Gissane angles for Group 1 (128.4 degrees) and Group 2 (134.5 degrees) (p=0.17) and postoperative Gissane angles for Group 1 (116.7 degrees) and Group 2 (118.8 degrees) (p=0.44) showed no statistically significant difference. There were a total of 3 wound complications in Group 1 versus 2 wound complications in Group 2 (p=0.76). There was no statistically significant difference in operative duration (p=0.97) or the number of unplanned returns to the OR between the two groups (p=0.77). Conclusion: When comparing the cannulated screw and plate and screw fixation techniques, there was no difference in restoration of the Bohler and Gissane angles. Both techniques had similar rates of postoperative complications and return to the OR. Our data suggests that fixation using cannulated screws alone versus sinus tarsi plate provide similar radiographic outcomes and risk of complications. The two techniques are also similar in terms of implant costs. Our results indicate that either technique effectively improves radiographic parameters.
The Prevalence and Clinical Significance of FHL Tears in Athletes with Posterior Ankle Impingement Surgery
Authors: Porter David A , Rund Angela , Kulwin Robert , Walrod Madison 
Published: October 2019

Category: Ankle, Hindfoot, Sports Introduction/Purpose: Posterior ankle pain in the athlete is common and thought to be caused by Flexor Hallucis Longus (FHL) tendon tear/tendinopathy or Os trigonum syndrome. The association of flexor hallucis longus (FHL) pathology in conjunction with PAIS has not been described. The purpose of this study is to report the prevalence of FHL tears in athletes who undergo surgical treatment for PAIS. We also report the outcome of 36 athletes treated with FHL repair with PAIS surgery and compare them to 122 athletes undergoing PAIS surgery without FHL tears. The utility of advanced imaging, standardized outcome scores at standard post-operative time intervals, return to sport (RTS) and time to RTS were all evaluated in the 158 athletes. Methods: Our clinical database was searched for appropriate surgical codes, and patients from 1996 through March 2016 were retrospectively collected. Inclusion criteria included surgical treatment of PAIS, age between ten and 50, and participation in recreational or competitive athletics. Exclusion criteria included other injuries that could affect return to sport or recovery process. 158 patients met these criteria, (36 dancers, 122 non-dancers). Pre-operative imaging, operative records, dorsiflexion range of motion at six weeks and one year postoperatively, and time to return to sport are reported. AAOS Foot & Ankle, and Lower Limb Core Module (FALLC) scores were obtained (six weeks, three months, and one year post-operatively). Questionnaire data and functionality scores were compared between the two groups using two-sample Student t-tests. Categorical data outcomes were compared using chi-square tests or Fisher’s exact tests. Results: 74/158 patients had magnetic resonance imaging (MRI) pre-operatively. 5/14 patients with an FHL tear had positive MRI suggesting an FHL tear, 9/14 patients with FHL tear had negative MRI (sensitivity of 0.26). FHL tears occurred in 36/158 (23%) of athletes with PAIS, 16/36 (44.4%) of dancers and 20/122 (16.4%) non-dancers. RTS did not differ between athletes with and without FHL tears, but time until RTS increased-average of 13.5 days (67.5 versus 81) with FHL repairs. Dancers with FHL tears reported increased foot pain and lower foot and ankle function at 3 months relative to those without tears. Scores were similar at one year. Conclusion: FHL tears in athletes undergoing surgical treatment for PAIS is 23% and in dancers can be as high as 44%. Pre- operative MRI has a poor sensitivity for FHL tears in this population. Concomitant FHL tear with repair during PAIS surgery does not decrease the rate of RTS or long term overall outcome. Overall, dancers have a higher rate of FHL tear at time of PAIS than non-dancers. FHL results in only a mild delay in RTS time. This is the first study to note FHL tear rate in association with PAI surgery.