bluuebunny/crossref_metadata_2025_split huggingface dataset:
Safety and Cost-Efficacy of Surgical Fixation of Isolated Ankle Fractures in a Free-Standing Ambulatory Surgical Center (ASC) vs. Hospital-Owned Outpatient Facility (HOPD)
Authors: Malik Azeem Tariq , Khan Safdar N , Quatman Carmen E , Ly Thuan V , Phieffer Laura 
Published: October 2019

Category: Ankle, Trauma Introduction/Purpose: Free-standing Ambulatory Surgical Centers (ASCs) typically provide uncomplicated surgical procedures in a non-hospital setting, and function as ‘focused factories’ that replicate the delivery of quality care while achieving lower costs as compared to hospital-owned outpatient facilities (HOPD). Despite an increasing interest towards outpatient foot and ankle surgery, few studies have compared the safety and cost-savings associated with surgical fixation of isolated ankle fractures in a free-standing ASC vs. a HOPD. Methods: The 2007-2014 Humana Administrative Claims (HAC) database was queried using Current Procedural Terminology codes to identify patients undergoing open reduction internal fixation (ORIF) for uni-malleolar (27766, 27769, 27792), bi-malleolar (27814) and tri-malleolar (27822, 27823) ankle fractures. Patients with polytrauma or those undergoing a concurrent surgical fixation of the upper extremity, hip, femur, knee or tibia were removed from the study to capture a relevant cohort of isolated ankle fracture patients. Location of surgery was identified using Service Location codes 22 (HOPD) and 24 (ASC). Propensity- score matching and multi-variate regression analyses were used to compare differences in 90-day complications, ED-visits and readmissions between the two groups. A 90-day cost comparison was also carried out to assess savings associated with surgery in an ASC vs. HOPD. Results: A total of 4,832 (80.1%) ankle fractures treated in a HOPD and 1,198 (19.9%) in a free-standing ASC were included in the study. Following propensity-score matching to account for differences in baseline demographics and clinical characteristics, each group consisted of 1,138 patients. Following multi-variate analyses, undergoing surgery in a free-standing ASC vs. a HOPD was not associated with a higher rate of 90-day complications (0.73 [95% CI 0.54 -1.00]; p=0.05), ED visits (OR 0.86 [95% CI 0.64- 1.16]; p=0.331) and readmissions (0.79 [95% CI 0.53 -1.18]; p=0.251). Furthermore, undergoing surgery in a free-standing ASC was associated with nearly $2500 cost-savings/case over the 90-day episode of care (ASC = $8,058 vs. HOPD = $10,619; p<0.001). Conclusion: Using national administrative claims of Commercial insurance beneficiaries, the results of the study show that performing surgical fixation of ankle fractures in a free-standing ASC is a safe and cost-effective option in a carefully selected patient population.
Prospective Evaluation of Vitamin D Levels and Stress Injury in Collegiate Female Long-Distance Runners
Authors: McDonald Elizabeth L. , Jarrell Kathleen , Raikin Steven M. , Nicholson Kristen , Fuchs Daniel , Winters Brian S. , Shakked Rachel J. 
Published: October 2019

Category: Lesser Toes, Midfoot/Forefoot, Sports Introduction/Purpose: The incidence of stress injury in female runners is reported in up to 21% of competitive runners, with female runners at higher risk for stress injury than men. Bone metabolism is closely linked with vitamin D, which may play a role in the high prevalence of stress fractures in female runners. Although runners who train outdoors in the southeastern US have adequate vitamin D levels, no study to date has evaluated runners in northeastern US. The aim of the study was to prospectively evaluate the relationship between 25-OH vitamin D serum levels and the incidence of stress injury in a cohort of collegiate competitive long-distance runners. Methods: 101 female collegiate runners from 7 Northeastern US colleges competing in varsity cross country were enrolled. Surveys were collected from all the study participants at the start of the fall cross country season reviewing demographics, weekly mileage, and medical history, including previous stress fracture incidence. Additionally, baseline (“summer”) serum 25-hydroxy vitamin D levels were obtained. Subjects insufficient in vitamin D (<30ng/mL) were supplemented with cholecalciferol (D3) 50,000 units weekly for 8 weeks and 2,000 units daily for an additional 1 month. In subjects with vitamin D insufficiency, repeat labs were performed at 3 months and repeat surveys distributed. To account for variation in season and geographical location, all subjects underwent repeat vitamin D labs at 6 months (”winter”). Fisher’s exact test was used to determine whether vitamin D levels were correlated with incidence of stress fracture. Results: 91/101 (90%) subjects with mean BMI of 20.5 and average age of 20 years completed all study requirements. The mean summer and winter vitamin D serum levels were 64.0 ng/mL (SD 16.6; range 28.9-112.9) and 45.0 ng/mL (SD 13.8; range 20.1- 90.6), respectively. One subject (1%) in the summer and 9 subjects (10%) in the winter were supplemented for vitamin D insufficiency. 7/10 (70%) insufficient subjects and 28/81 (35%) vitamin D sufficient subjects reported a stress fracture during the study period. Patients that had an insufficient vitamin D result were significantly more likely to have a stress fracture during the study period (p=0.041; Table 1). The mean change in vitamin D level from summer to winter was -19.7 (SD 14.4; range -60.5- 60.7). Conclusion: The high rate of stress fractures in this cohort of collegiate female long-distance runners is greater than previously reported. Runners who are vitamin D insufficient are at a higher risk to incur a stress fracture. The results of the study also highlight the considerable seasonal variance in vitamin D levels amongst female collegiate long-distance runners in the northeastern US. Further study is needed to determine whether vitamin D supplementation reduces the risk of stress fractures.
The Retrograde Drilling for Osteochondral Talar Lesion in Children
Authors: Minokawa So , Yoshimura Ichiro , Kanazawa Kazuki , Hagio Tomonobu , Yamamoto Takuaki 
Published: October 2019

Category: Ankle, Arthroscopy Introduction/Purpose: Osteochondral talar lesions (OCL) are infrequent in children, and little is known about the treatment and clinical outcome of these defects. Clinicians normally first attempt nonoperative treatment of these lesions, but if such treatment fails, surgical many treatments including retrograde drilling (RD), are attempted. RD is usually reserved for large OCLs with intact overlying cartilage. Good clinical outcomes have been reported in RD. However, the clinical outcomes of RD for OCL in children remains unclear. The purpose of this study was to evaluate the clinical and radiographic outcomes of RD in skeletally immature children. Methods: From January 2015 to April 2018, RD was performed on eight feet with OCL in six consecutive patients in skeletally immature children. Arthroscopic lateral ankle ligament repair was also performed in one of the eight feet, and one foot was excluded; therefore, we studied seven feet in five patients. The patients comprised three boys and two girls with a mean age at surgery of 11 (range, 9–12) years. All patients were followed for a minimum of 6 months postoperatively, the average follow-up was 19.1 (range, 8–39) months. All patients were grade 0, determined according to a modified Pritsch classification system. All patients were evaluated for Japanese Society for Surgery of the Foot (JSSF) scale and radiographic outcomes at preoperatively and postoperatively final follow up. Results: The average JSSF scale improved from 79.4 points (range, 69–90 points) to 100 points in all feet at final follow-up (p<0.01). The postoperative size of OCL using CT findings was improved than preoperative size. According to the postoperative computed tomography (CT) findings, four feet were good, three foot were fair. There were no incidences of postoperative complications. Conclusion: In our study, we suggest that RD for OCL in skeletally immature children is effective surgical treatment.
MRI Analysis for Clarification of Mechanism of Ankle Osteoarthritis: Prediction of Talar Lateral Process Impingement from X-Ray Findings
Authors: Mitsui Hiroyuki , Hirano Takaaki , Akiyama Yui , Endo Wataru , Karube Tomoko , Haraguchi Naoki , Niki Hisateru 
Published: October 2019

Category: Ankle Arthritis Introduction/Purpose: We have previously elucidated the pathological condition of osteoarthritis (ankle OA) by MRI by examining the relationship between X-ray findings and bone marrow edema (BME) and found a relationship between talar lateral process impingement (TLPI) in the subtalar joint and the incidence of BME in the talocrural joint as well as found an association of these MRI findings with clinical symptoms. In the present study, we focus on the three talar movements inversion, dorsiflexion, and forward displacement to report on our survey of X-ray findings involved in occurrence of TLPI. Methods: We examined MRI imaging for 70 feet of 68 cases, which has diagnosed ankle OA in our hospital. X-ray measurements of the movement of the talus regarding the TMM, TBM, TTA, LTMT, and LTC angles as well as the T-T ratio(refer to the figure) were obtained. The incidence of BME on MRI was calculated after dividing the talus, the subtalar joint, and Chopart’s joint into 22 regions; cases where BME was observed in the talar lateral process were defined as TLPI (+). For statistical analysis, the study sample was divided into two groups depending on the presence/absence of TLPI, which their respective incidences of BME and values of X-ray measurement were compared using a t-test. Furthermore, for values in which significant differences were observed, cut-off values were obtained from the ROC curve, and the factors that were most independently involved in the incidence of TLPI were identified using multivariate analysis. Results: On comparing the groups with the presence or absence of TLPI, the incidence of BME occurring at a region other than the lateral process was significantly higher in the TLPI (+) group, and significant differences were found for all values of X-ray measurement except for T-T Ratio. The multivariate logistic regression analysis with cut-off values at TMM = 46° or more, TBM = 77° or less, TTA = 4° or more, LTMT = 8° or more, and LTC = 35° or less demonstrated that LTC (odds ratio: 4.22, 95% CI: 1.28–14.0, p = 0.02) and TMM (odds ratio: 3.44, 95% CI: 1.12–10.6, p = 0.03) were significantly involved in the incidence of TLPI. Conclusion: Results of this study have led to the speculation that the incidence of TLPI is closely related to the positional relationship of the peripheral opening of the medial malleolus and the talocalcaneal bone as well as to the varus and dorsiflexion of the ankle joint. These new findings could be used as a new index to predict the incidence of TLPI.
Landmark Technique vs Ultrasound Guided Approach for Posterior Tibial Nerve Block in Cadaver Models
Authors: Morris Sara Elizabeth , McKissack Haley , Moraes Leonardo V. M. , Viner Gean C. , Jones James R. , Tedder Chandler , Kukreja Promil , Chinnakkannu Karthikeyan , Jha Aaradhana J. , Shah Ashish B. 
Published: October 2019

Category: Ankle, Basic Sciences/Biologics Introduction/Purpose: Until recently, many regional anesthetic blocks were performed without the assistance of ultrasound, relying on methods such as anatomical landmarks and nerve stimulation. The use of ultrasound for peripheral nerve blocks has proven extremely useful for improving the efficacy of many regional anesthetic techniques. There remain a few nerve blocks which have lagged in employing the assistance of ultrasound consistently, one of which is the ankle block. This block is commonly utilized for either surgical anesthesia or post-operative analgesia for a variety of foot and ankle procedures. In this study, we compared the accuracy of traditional landmark technique with an ultrasound guided approach for ankle block by assessing the spread of injectate (dye) along the posterior tibial nerve (PTN) in cadaver models. Methods: Ten below-knee cadaver specimens were used for this study. Five were randomly chosen to undergo landmark guided PTN blocks, and five were selected for ultrasound-guided PTN blocks. The landmark technique was performed by identifying the medial malleolus and Achilles tendon and inserting the needle (4 cm long, 21G Braun® Stimuplex) at the midpoint of the two structures, aiming toward the medial malleolus and advancing until bone was contacted. 2 cc of blue acrylic dye was injected at this location. The ultrasound technique was performed with a linear probe identifying the medial malleolus and the PTN. The needle was advanced in-plane with a posterior to anterior trajectory until the tip of the needle was adjacent to the nerve. 2 cc of blue acrylic dye was injected surrounding the nerve. The extremities were then dissected to determine which nerves had been coated with dye. Results: 100% of the ultrasound guided blocks resulted in completely stained PTN with dye. In the landmark group, only 40% of the landmark technique blocks resulted in completely stained PTN with dye. Of the nerves not stained with dye, 2 were noted to have had dye injected posterior to the nerve and 1 was noted to have had dye injected into the flexor digitorum longus tendon. Conclusion: The base of evidence has dramatically increased in recent years in support of the use of ultrasound in regional anesthesia. This study substantiates the superiority of ultrasound guidance for ankle block by demonstrating a 100% success rate amongst the ultrasound guided group.
Fixation Technique Using PLLA Pins Gives Good Clinical Results Regardless of Bone Condition in Osteochondral Lesion of Talar Dome
Authors: Nakasa Tomoyuki , Ikuta Yasunari , Tsuyuguchi Yusuke , Ota Yuki , Kanemitsu Munekazu , Adachi Nobuo 
Published: October 2019

Category: Ankle Introduction/Purpose: Osteochondral lesion of the talus (OLT) has various treatment options which are chosen depending on the stage, size and cartilage condition. The fixation technique can restore the natural congruency with the hyaline cartilage. However, it is not clear whether a bone condition such as the disruption of the subchondral bone plate will affect the clinical results after the fixation of the osteochondral fragment. We hypothesized that even if the subchondral bone plate were disrupted, if the articular cartilage condition in the osteochondral fragment were good, then the clinical results of the fixation technique would be good. The aim of this study was to explore whether the fragment’s bone condition affects clinical outcomes including second look arthroscopy. Methods: Eighteen ankles in 17 patients, which had undergone the fixation technique using poly-L-lactide (PLLA) pins, were included. The mean follow-up period was 18.8±8.9 months. They consisted of 10 males and 7 females, with a mean age of 20.1±10.1 years. Based on the fragment’s bone condition on preoperative CT, ankles were divided into 3 groups; normal, segmentation, and absorption groups. The American Orthopaedic Foot & Ankle Society (AOFAS) score were evaluated both pre and post surgery. On MRI, the BME area was measured, and stability, incorporation, subsidence, and the surface of the articular cartilage of the fragment were evaluated. Second look arthroscopic findings were evaluated in 13 ankles. The repair of OLT was assessed according to the criteria of the ICRS which are allocated for the degree of filling defect by repair tissue, integration, and surface appearance of the repair site. Results: The AOFAS score before surgery significantly improved from 72.1±2.8 points to 98.6±3.3 points at the final follow-up in all ankles. In each group, the AOFAS score improved and there were no significant differences in AOFAS score among the 3 groups at final follow-up. MRI at 1 year showed good incorporation and cartilage surface in all groups, but the bone marrow lesion in the absorption group was significantly larger than that in the other groups. In the second look arthroscopic findings, the ICRS scale for the normal, segmentation, and absorption groups produced 10.6±1.7 points, 9.8±1.9 points, and 10.7±1.2 points, respectively. Conclusion: Good clinical results including those of second look arthroscopy for osteochondral fragment fixation using PLLA pins in OLT were obtained, even in the case of disruption of the subchondral bone plate. Since the fixation procedure can restore the native contour of the articular cartilage surface, this surgical procedure is a viable option for large OLT lesions regardless of bone condition in the osteochondral fragment.
New Model Foot and Ankle Service Pathway: Pilot Results 2 Years
Authors: Nicolas Andrea Pujol , Ramaskandhan Jayasree Ramas , Siddique Malik 
Published: October 2019

Category: Service improvement Introduction/Purpose: The foot and ankle services at NUTH incorporates both elective and trauma services. The elective service carries out on average 10,500- 11,000 review appointments/ year and 4000-4500 new patient appointments/year. The waiting times for new out-patient appointments were 8-14 weeks. A new pathway was designed with the aim to improve 18 week national target compliance, improve departmental efficiency, and improve patient satisfaction. Methods: A new initial assessment clinic pathways was designed were all new patients are seen in a one hour slot one stop clinic by a dedicated Extended Scope Practitioner. History and clinical examination are taken as well as initial Proms questionnaire, x-ray assessment followed by gate analysis including pain map, treadmill assessment and plantar pressure analysis. A consultant led MDT review of the finding is performed the same week where plan for treatment or further investigations is formulated. Results: A total of 1792 patients had the initial assessment through the new clinic pathway between March 2016 and March 2018. The average waiting time for the initial assessment has been gradually reduced from 14 to 3 weeks. We obtained over 96% patient satisfaction in enhancing patient experience. Conclusion: Our new clinic model has shown to improve efficiency, patient satisfaction and reduce waiting times.
An Anatomic Approach for Intramedullary Screw Fixation of Fifth Metatarsal Fracture: A Clinical and Radiographic Study
Authors: Niu Shuo , Mirza Faris , Schwartz Andrew , Labib Sameh 
Published: October 2019

Category: Ankle, Sports, Trauma Introduction/Purpose: Intramedullary screw fixation is the most common surgical intervention for treating Jones fractures and diaphyseal stress fractures of the fifth metatarsal. Proper screw placement is paramount to surgical success. There have been studies describing more traditional antegrade and retrograde approaches, dependent upon fluoroscopy and guidewires. However, we propose a novel, more efficient surgical approach that utilizes anatomical landmarks and plantarflexion angle during screw fixation. The purpose of this study was to evaluate screw position and radiographic healing parameters, return to sport, and patient-reported outcome measures after utilization of our technique for screw fixation of the fifth metatarsal fracture. Methods: This is a retrospective review from 2007 to 2017 of clinical records and radiographs of 31 consecutive patients who had fifth metatarsal fracture open reduction internal fixation using anatomical landmarks and plantarflexion angle (Johnson, Labib and Fowler 2004). The classification of the fracture, surgery time, time to union, and post-operative complications were collected. Return to sport, Tegner score, the Foot and Angle Disability Index (FADI) Sports Module, and the Short Form 12 Physical and Mental Health Composite Scale (SF-PCS/MCS) were obtained through phone interview. Post-operative X-ray analysis, including screw position and bone healing percentage, were evaluated. Post-operative screw position was described as either center-center, oblique, or cortical breach on anteroposterior, lateral or oblique view. Fisher’s exact test was used to determine the difference among frequencies of each screw position. P<0.05 was considered significant. Results: Patient and surgical information were shown in Table 1. Average post-operative follow-up was 98 (36-227) days. Screws were well center-center positioned at all three views on post-op X-ray in most cases (all p<0.001). No case showed the screw protruding into tarsometatarsal joint or cuboid impingement. Average phone interview follow-up was 5.4 (1.0-11.1) years. Tegner scores showed no difference (p=0.58) when compared between pre-injury (6.4) and current level (6.1). At the terminal follow-up, average FADI-sports was 87.2 (37.5-100), SF-PCS was 50.7 (27.3-55.6), and SF-MCS was 59.7 (52.9-67.2). In addition, 12 of 15 (80%) the college or professional athletes (1 lost to follow-up) returned to the same level sports after the surgery. Conclusion: This study quantified the benefit of a novel technique for intramedullary screw fixation of fifth metatarsal fracture that was reliable and reproducible. It facilitated accurate screw positioning, dependable union, and accompanying positive return to sport and patient-reported outcome measures.
A New Minimally Invasive Technique for Achilles Tendon Repair in the Supine Position
Authors: O’Donnell Seth , Velasco Brian , Whitehouse Brianna , Kwon John Y. , Miller Christopher P. 
Published: October 2019

Category: Tendon Introduction/Purpose: Achilles tendon repairs are a common procedure that, historically have been plagued by complications. Recent advanced in both operative and non-operative techniques have changed the landscape for this procedure. Minimally invasive approaches have become far more common which have improved outcomes by decreasing the risk of wound complications. However, a further limiting factor is the traditional need to place the patient prone. This requires higher levels of anesthesia and careful positioning of the extremities. We present a technique that eliminates the need for prone position while maintaining the advantages of a minimally invasive approach. Methods: The authors present a novel surgical technique to repair the Achilles tendon. The patient is maintained in the supine position on the pre-operative stretcher. The leg is externally rotated. A direct medial incision is made at the rupture site and the tendon is repaired by passing suture percutaneously through the eyelets of a bent ring forcep and delivered into the wound. This is performed proximally and distally and then the sutures are tied together to complete the repair. Clinical case time, wound complications and short term outcomes will be reported. Results: 6 patients results will be presented including operative case times which average 57 minutes from the time the patient enters the room until they exit the room and arrive in PACU. This represents a decrease of nearly 30 minutes of OR time required for intubation and prone positioning. 4/6 of the patients received only MAC anesthesia and a nerve block with no tourniquet. The first two patients had general anesthesia with an LMA. 6 month PROMIS and FAAM scores will be obtained but are not available at the time of abstract submission. Conclusion: We present a novel technique to repair an Achilles tendon with the patient in the supine position. The technique is reliable and can be performed with a minimal learning curve. The operative case times are faster as the patient is kept on their recovery stretcher and do not need to be positioned prone. This decreases the amount of anesthesia required for the surgery as well. The authors believe that eliminating prone positioning will be both safer for the patient and results in a faster surgery without compromising outcomes.