bluuebunny/crossref_metadata_2025_split huggingface dataset:
Patients Reported Outcomes (PROMS) in Hallux Valgus and Rigidus Surgery, Is There Any Difference?
Authors: Alkhreisat Mohammad , Nicolas Andrea Pujol , Ramaskandhan Jayasree Ramas , Mousa Adham , Qasim Sultan , Siddique Malik 
Published: October 2019

Category: Bunion Introduction/Purpose: There is paucity of literature comparing foot and general health status including quality of life between patients presenting with Hallux Valgus and Hallux Rigidus and to compare the outcomes of people how had surgery in either one. We compared foot specific patient reported disability and general health status between patients presenting with Hallux Valgus and Hallux Rigidus pre and post-surgery. Methods: All patients operated between June 2016 and December 2017 with a diagnosis of primary Hallux Valgus or Hallux Rigidus were invited to the study. Patients were grouped based on diagnosis into Group A (Hallux Valgus) and Group B (Hallux Rigidus). All patients received a Pre-Operative and post-operative questionnaire with a minimum of 6 months follow up. Differences were studied between groups for scores of MOX-FQ, EQ-5D (UK) and Foot and Ankle outcomes scores (FAOS) comparing both pre and post-operative. Results: There were 53 patients with Hallux Valgus and 46 patients with Hallux Rigidus of 1st MTPJ. Pre-operatively in MOX-FQ both groups reported similar level of pain (p=0.776), difficulty with walking/ standing (p= 0.960) and restriction with social activity because of foot symptoms (p=0.683). Following surgery both groups significantly improved in all domains (p< 0.001). Post- operatively there was no difference between both groups for MOX-FQ (pain, walking, social domains; p>0.05), EQ-5D general health score (p=0.404) and FAOS domains for pain (p=0.653), symptoms (p=0.230), ADL (p=0.587), and quality of life (p=0.876). But all scores improved significantly from pre-op to post-op for both groups (p<0.001). Conclusion: There is no difference in foot related quality of life, general health status and higher functional disability levels between patients presenting with Hallux Valgus vs. Hallux Rigidus before surgical intervention. The impact of these conditions on disability levels remain the same, amidst the difference in pathology. Surgery for both pathologies equally improves foot related quality of life and functional disability levels equally between the 2 pathologies keeping in mind the difference in surgical indications as well as type of surgery performed.
Intra- and Intraobserver Reliability of Radiologic Flatfoot Parameters Before and After Surgery
Authors: Bock Peter 
Published: October 2019

Category: Hindfoot Introduction/Purpose: Various radiological parameters are used to evaluate a flatfoot deformity and their measurements may differ. The aims of this study were to answer the following questions: 1) Which of the 11 parameters have the best inter- and intraobserver reliability in a standardized radiological setting? 2) Are pre- and postoperative assessments equally reliable? 3) What are the identifiable sources of variation? Methods: Measurements of the 11 parameters were recorded on anteroposterior and lateral weightbearing radiographs of 38 feet before and after surgery for flatfoot, by three observers with different experience in foot surgery (A, ten years; B, three years; C, third-year orthopaedic resident). The inter- and intraobserver reliability was calculated. Results: Preoperative interobserver reliability was high for four, moderate for five, and low for two parameters. Postoperative interobserver reliability was high for four, moderate for five, and low for two parameters. Intraobserver reliability was excellent for all parameters preoperatively as recorded by observer A (PB) and B (MP), and for eight parameters as recorded by observer C (SR). Intraobserver reliability was excellent for ten parameters postoperatively as recorded by observer A and B, and for eight parameters as recorded by observer C. Conclusion: The following parameters can be recommended. For preoperative and postoperative evaluation of flatfoot: anteroposterior, talonavicular coverage angle; lateral, talometatarsal I angle, calcaneal pitch angle, and cuneiform medial height (high interobserver reliability); and anteroposterior, talometatarsal II angle; lateral, talocalcaneal angle, tibiocalcaneal angle (moderate interobserver reliability). For more experienced observers, we also recommend the anteroposterior talometatarsal I angle (moderate reliability). The inter- and intraobserver reliability for most parameters were similar pre- and postoperatively. The experience of the observer and the definition and ability to measure the parameters themselves were sources of variation.
Ankle Gravity Stress View in the Seated Position: A Technical Tip
Authors: Briceño Jorge , Chien Bonnie , Miller Christopher , Velasco Brian , Kwon John Y. 
Published: October 2019

Category: Ankle Introduction/Purpose: Diagnosis of mortise instability in the apparent isolated lateral malleolus fracture can be challenging and often relies on stress radiography. While the gravity stress view (GSV) is commonly utilized, it traditionally requires the patient to assume the lateral decubitus position for imaging of the ankle. This can be difficult and uncomfortable for the patient and may be unsafe in particular situations. Furthermore, transferring the patient back and forth to obtain this positioning is time-intensive for the radiology technician and disruptive to clinic throughput. Therefore, we describe a simple technique that allows acquisition of the GSV of the ankle while the patient remains seated. The technique involves minimal patient movement and is simple for the staff to position appropriately. Methods: The patient is seated on either a stable office chair with arms for safety or in a wheelchair. The affected limb is then placed on a padded stool with the foot extended past the edge of the stool. The patient is instructed to maintain the ankle in a comfortable resting position. They are then encouraged to externally rotate at the ipsilateral hip. If needed, a small bump can be placed underneath the contralateral hip to further increase external rotation of the affected limb at the hip. The ankle and foot should be approximately 15 degrees internally rotated relative to the plane of the floor once the leg has been appropriately positioned. The leg should be held straight with the ankle at the level of the chair seat. This places the ankle in an optimal angle for obtaining a mortise view. The radiograph is then obtained in standard fashion. Results: N/A Conclusion: Obtaining the GSV in the seated position offers several advantages. First, the patient is placed in a seated position, which is more time-efficient than transferring the patient to the radiology table and avoids the potential danger of patients falling. Second, external rotation of the hip is generally well-tolerated in isolated leg injuries. Third, this positioning more reliably places the ankle in approximately 15 degrees of internal rotation to obtain the optimal mortise view and assess mortise symmetry. Finally, patient comfort is increased as this technique obviates transferring patients or placing their hip directly on a rigid radiology table.
Displacement of Sequential Syndesmotic Ankle Injuries Assessed by a 3D Weightbearing CT
Authors: Burssens Arne , Krähenbühl Nicola , Vermue Hannes , Davidson Nathan , Weinberg Maxwell , Zhang Chong , Saltzman Charles L. , Barg Alexej 
Published: October 2019

Category: Ankle Introduction/Purpose: Syndesmotic ankle injuries are challenging to diagnose, since current 2D imaging techniques try to quantify a 3D displacement. Therefore, our aim was two-fold: to determine displacement of sequential syndesmotic ankle injuries under various amounts of load using a 3D weightbearing CT (WBCT) and to assess the relation with current 2D imaging. Methods: Seven paired male cadaver specimens were included (tibia plateau to toe-tip) and mounted into a custom-built frame. WBCT scans were obtained after different patterns of load (0 kg or 85 kg) were combined with torque (0 Nm or 10 Nm external rotation). These conditions were repeated after each ligament condition: intact ligaments, sequential sectioning of the anterior inferior tibiofibular ligament (AITFL), deltoid ligament (DL), and interosseous membrane (IOM). CT images were segmented to obtain 3D models. These allowed quantification of displacement based on the position of computed anatomical landmarks in reference to the intact position of the fibula. A correlation analysis was performed between the 2D and 3D measurements. Results: The effect of torque caused significant displacements in all directions (P<0.05), except for shortening of the fibula (P>0.05). Weight caused a significant lateral (mean=-1.4 mm, SD=1.5) and posterior translation (mean=-0.6 mm, SD=1.8). The highest displacement consisted of external rotation (mean=-9.4°, SD=6.5) and posterior translation (mean=6.1 mm, SD=2.3) after IOL sectioning combined with torque (Fig. 1). Pearson correlation coefficients were moderate (range 0.31-0.51, P<0.05). Conclusion: Torque demonstrated superiority over weight in detecting syndesmotic ankle instability after 3D analysis. The clinical relevance of these findings can improve diagnosis by incorporating rotatory platforms during imaging and treatment strategies by providing appropriate stabilization against rotation.
The Hindfoot Alignment in Total Knee Arthroplasty: A Systematic Review
Authors: Burssens Arne , De Roo Dries , Barg Alexej , Van den Bossche T , Pfeufer Daniel , Saltzman Charles L. , Victor Jan 
Published: October 2019

Category: Hindfoot Introduction/Purpose: Patients with a hindfoot deformity pose a particular challenge when performing a total knee arthroplasty (TKA). This could be attributed to the lack of insights concerning hindfoot alignment outcome. Our objective was to perform a systematic review of the literature to investigate the influence of TKA on hindfoot alignment and vice-versa. Methods: This systematic review was performed in accordance to PRISMA guidelines; the original protocol is registered on PROSPERO (ID: 106980). The following electronic databases were searched to identify capable studies: Pubmed, EMBASE, Web of Science, Google Scholar, and Cochrane Library. To ensure the quality of the review, a quality assessment was performed according to the MINORS criteria. The mean MINORS score was 9.5 (range 7-12) and concurred with a good quality of the obtained studies. Results: Sixteen identified articles met the review criteria: six prospective cohort studies, nine retrospective studies, and one case-control study. Five articles reporting on clinical outcomes were identified; a pre-operative hindfoot deformity negatively influenced TKP outcome (N=4) or demonstrated no influence (N=1). Thirteen articles reporting on radiographic outcomes were identified. Five studies reported a significant improvement (P < 0.05) of hindfoot alignment after TKA, two studies demonstrated improvement limited to valgus hindfeet, seven studies observed a significant (P < 0.05) correlation between knee and hindfoot alignment, and two studies reported the association between hindfoot OA in patients undergoing TKA. Two studies reporting biomechanical outcomes were identified; these reported a shift of the weighbearing axis after TKA as a result of the remaining hindfoot deformity. Conclusion: TKA can improve the alignment of valgus hindfeet, but improvement was less pronounced in varus hindfeet. Furthermore, a worse clinical outcome is expected after TKA in patients with concomitant ankle OA. A remaining hindfoot deformity shifts the weightbearing axis, which could shorten the survival of the total knee prosthesis.
Peripheral Nerve Block Use in Ankle Arthroplasty and Ankle Arthrodesis: Utilization Patterns and Impact on Outcomes
Authors: Chan Jimmy J. , Guzman Javier Z. , Chan Jesse C. , Zubizarreta Nicole , Poeran Jashvant , Vulcano Ettore 
Published: October 2019

Category: Ankle, Ankle Arthritis Introduction/Purpose: Ankle arthrodesis (AA) and total ankle arthroplasty (TAA) are often associated with significant postoperative pain; this may be mitigated by the use of peripheral nerve blocks (PNB). While smaller studies suggest PNB to be an effective pain management option in foot and ankle procedures, large scale comparative effectiveness data in ankle arthrodesis and TAA is lacking. Therefore, the purpose of this national study was to evaluate PNB utilization patterns and its impact on outcomes such as opioid utilization. Methods: This retrospective cohort study utilized data from the nationwide Premier Perspective claims database (2006-2016) on AA (n=10,049) and TAA (n=4,977) procedures. Mixed-effects models estimated associations between PNB use (defined from inpatient billing) and opioid utilization (during the total hospitalization period and specified by each day), hospitalization costs, length of stay (LOS), admission to skilled nurse facility (SNF), opioid-related complications, and 90-day readmission. We report odds ratios (OR, or % change for continuous outcomes) and 95% confidence intervals (CI). Results: Overall, PNB was utilized in 8.6% of TAA and 8.5% of AA. Both procedures demonstrate increased utilization of PNB from 2006 to 2016 (2.7% to 11.7% and 5.5% to 11.7% for TAA and AA, respectively). In general, PNBs were utilized less in non- teaching and smaller hospitals and among surgeries performed by a podiatrist (compared to orthopaedic surgeon). After adjustment for relevant covariates, PNB use was significantly associated with decreased opioid utilization during the total hospitalization period for both TAA (-15.7%, CI 22.8; 7.9%) and AA (-16.0%, CI 21.9%; 9.7%); this was particularly driven by a decrease in opioid utilization on the day of surgery. PNB use was not associated with reductions in LOS, cost of hospitalization, discharge to SNF, complications, 90-day readmission. Conclusion: In this first national study on PNB use in ankle procedures we found an overall low use of PNB while an increasing trend in utilization was observed. Importantly, PNB use was associated with significant opioid-sparing effects (especially on the day of surgery), while no effects were seen for other outcomes. Given the current low utilization rate, increased use of this analgesic technique may translate into more benefits in terms of clinical outcomes and resource utilization.
Effect of BMP-2 with Microfracture on Osteochondral Defect in a Rabbits Talus
Authors: Dang Le Hoang Nam , Lee Kwang-Bok 
Published: October 2019

Category: Ankle, Basic Sciences/Biologics Introduction/Purpose: Microfracture is a technically safe, simple and cost-effective treatment option for osteochondral defect of the talus. However, fibrous tissue and fibrocartilage represent the predominant repairing tissues derived from these procedures and these tissues types do not exhibit the mechanical properties of native hyaline cartilage, long time for cartilage reconstruction and long-term failure results. Bone morphogenetic protein-2 (BMP-2) has been shown to stimulate matrix synthesis and increase in synthesis of cartilage-specific collagen type IIB thereby enhance regeneration of articular cartilage in vitro. The purpose of this study is to evaluate the treatment ability of combining BMP-2 with microfracture on osteochondral defect in rabbit talus. Methods: Full-thickness chondral defects (3 x 3 x 2 mm) was created in the center talus dome. Twenty four male white New Zealand rabbits were divided into four groups of 6 animals into each group dependent on treatment method; Group I (control, no treatment), II (microfracture only), III (10 µL rhBMP-2 treatment), IV (microfracture combine with 10 µL rhBMP-2 treatment). The animals were sacrificed at 2, 4, 6 weeks post operatively. The macroscopic assessment of the repaired tissue was evaluated using the International Cartilage Repair Society (ICRS) Macroscopic Score, which considers the degree of defect repair, the integration to the border zone, and the macroscopic appearance. Subchondral bone regeneration on defect was evaluated by micro-CT scan and the histological findings were scored by using a modified version of the established scoring system for osteochondral repair described by Wakitani, immunohistochemical staining was used for analysis of collagen type I and II. Results: : Excessive bone formation that originated from the subchondral bone region was not observed in any sample. Micro-CT shows higher subchondral bone regeneration on defect in group III, IV than group I, II at 4 and 6 weeks, respectively. According to macroscopic and histological results, group V shows higher quality of cartilage and faster cartilage regeneration compare with another group. In immunohistochemical analysis, group IV shows stronger positive staining for collagen type II in the area of the defect. Conclusion: These findings indicate that the combination BMP-2 with microfracture is effective at accelerating and improving quality of full-thickness cartilage defect repair in a rabbit talus model.
Ankle Mortise Instability in Multiple Hereditary Exostoses
Authors: Ebaugh M Pierce , Grenier Greg , Singh Satbir , Abousamra Oussama , Klingele Kevin 
Published: October 2019

Category: Ankle, Ankle Arthritis, Pediatric Foot and Ankle Introduction/Purpose: Ankle valgus has been reported in 50% of patients with multiple hereditary exostoses (MHE) and, untreated, results in early arthrosis. Widening of the ankle mortise has also been reported; however, there has been a lack of data regarding its natural history and management. Alterations of mortise anatomy result in poor functional outcomes and accelerated arthrosis of the ankle. The aim of our study was to report the characteristics and outcomes of mortise widening in a group of patients with MHE. Methods: A total of 13 patients with MHE and mortise widening (16 ankles) were identified. Age, sex, BMI, laterality, origin of osteochondroma, pain, instability, clinical deformity, operative data, and complications were recorded. Mortise (M), Talocrural angle (TC), and Tibiotalar angle (TT) measurements were collected on preoperative and last follow up radiographs. The majority of patients underwent medial distal tibia hemiepiphysiodesis. Post-surgical AOFAS and SF36 scores were collected. Results: Preoperatively, no patient complained of instability, however, 9/16 ankles were painful and 14/16 were clinically in valgus. Patients underwent surgery at an age of 11.8 years (9.7-15). Radiographic and clinical follow up were 2.6 years (0.2-7.3) and 6 years (1.5-11.7), respectively. There were no significant differences between pre/postoperative M, TC, TT angles. Operative patients improved mean M (5.17 to 4.63 mm) and TT (8.71 to 4.54 degrees), neither angle reached normal values. TC (fibular length) was within normal limits (82.2 to 84.8). Questionnaires were obtained for 8/16 ankles, at a mean age of 19 years (13-25.1). The average AOFAS score was 66.7 out of 100. Patients scored 8.6/10 for alignment, 32/40 for pain, 25.6/50 for function. SF-36 scores were excellent. Conclusion: The improvement in M and TT was modest and their values remained outside the normal limits. TC angle was within normal limits but displayed an overall fibular shortening and thus, decreased lateral buttress with potential for talar shift. This was reflected in the mean functional and overall AOFAS score. However, our patients are functionally compensating as evidenced by SF36 scores. More studies are needed to optimize the management of MHE patients with ankle malalignment. Earlier valgus correction and possible addition of fibular lengthening to simultaneously address mortise widening may need to be considered to prevent early ankle arthritis.
Natural History of 321 Flatfoot Reconstruction Patients Over a 14 Year Period Performed at a Single Institution
Authors: Goss Madison , Stauch Chris , Lewcun Joseph , King Jesse , Fritsche Madelaine , Juliano Paul , Aynardi Michael 
Published: October 2019

Category: Midfoot/Forefoot Introduction/Purpose: Outcomes following surgical reconstruction for acquired flatfoot deformity secondary to posterior tibial tendon dysfunction have been well described. However, the majority of studies have a limited number of patients or short to mid- term follow-up. The purpose of this study was to report the natural history, demographics, and mechanisms of treatment failure for patients undergoing flatfoot reconstruction at a single institution by a single surgeon. Methods: With IRB approval, 321 consecutive patients undergoing flatfoot reconstruction during a 14-year period were included in this study (February 2002 through October 2016). All procedures were performed by a single surgeon (PJJ) at our institution. Demographic data, surgical data, clinic notes, and radiographs were available for review. Exclusion criteria included patients without electronic records or incomplete data. Failure was defined as a need to return to the operating room for revision surgery. Statistical analysis was performed. Results: 321 consecutive patients underwent flatfoot reconstruction from 2002-2016. The majority of patients were female (83.2%) with left laterality (58.6%) & a body mass index classified as overweight (21.5%) or obese (56.4%). 13.7% of patients were diabetics, and 18.4% were current smokers. 54 patients (16.8%) experienced treatment failure. Painful calcaneal hardware requiring removal occurred in 11.8% of patients, conversion to triple arthrodesis occurred in 3.45%, and wound complications or infection requiring irrigation & debridement occurred in 1.87%. There were no mortalities reported within 90 days. There were 3 symptomatic deep vein thromboses, none requiring surgical intervention, & no pulmonary embolisms. A significant increase in relative risk of treatment failure was calculated for female gender, current cigarette use, & age under 60 (3.4 p=0.0005/1.9 p=0.0081/1.8 p=0.042). Conclusion: This study represents the largest series of patients undergoing flatfoot reconstruction by a single surgeon at a single institution. Although retrospective, the results provide valuable insight to the natural history of patients undergoing this procedure. The overall complication rate and treatment failure rates are low and similar to those previously reported in the literature. Patients with female gender or under 60 years of age should be notified of their increased relative risk of treatment failure & counseled accordingly. Smoking cessation is recommended to reduce the risk of treatment failure.