bluuebunny/crossref_metadata_2025_split huggingface dataset:
Posteromedial Fracture Fragment of the Posterior Malleolar Fracture: A Closer Look
Authors: Heyes Gavin , Vosoughi Amir Reza , Jayatilaka Malwattage Lara Tania , Fischer Benjamin , Molloy Andrew P , Mason Lyndon W 
Published: October 2019

Category: Ankle, Trauma Introduction/Purpose: To date, there have been no studies describing the characteristics of posteromedial fragment in the posterior malleolus fracture. The aim of this study was to investigate the variability of posteromedial fracture fragments in trimalleolar fractures to enable better surgical planning. Methods: In our department, data on all ankle fractures treated surgically are prospectively collected on our internal database. We collated data from August 2014 to October 2018 for this study. All Mason and Molloy type 2B fractures from our database were identified to analyse the preoperative computed tomography scan. The morphology of the fracture fragment was categorized on whether the fracture appeared to be an intraarticular pilon fragment (i.e. caused by impaction of the talus) or an avulsion extraarticular fracture (i.e. caused by the pull of a ligament). The fracture fragment characteristics were analysed for both the posteromedial and posterolateral fragments. Results: The fracture patterns of the posteromedial fragment were investigated in 47 cases (mean age, 46.6; 11 male, 36 female). Morphologically, the fracture could be divided into 2 subtypes, 1) a large pilon type intra-articular fragment (mean of X axis: 32.97 mm, Y: 30.69 mm, Z: 31.74 mm) present in 29 cases with mean Interfragmentary angle of 32.09 and back of tibia angle of 32.66 degrees. This was seen in 25 out of 27 cases with supination injury pattern. 2) A small extra-articular avulsion fragment (mean of X axis: 9.56 mm, Y: 13.22 mm, Z: 11.53 mm) present in 18 cases with mean Interfragmentary angle of 10.97 and back tibia angle of 10.06 degrees. It was seen in 80% of pronation injuries. Conclusion: The posteromedial fragment of posterior malleolus fracture can be morphologically subtyped into an avulsion type and pilon type variants. The avulsion type is more common in pronation injuries, likely the result of the pull of the inter-malleolar ligament, and the pilon type is more common in supination injuries, likely the result of the rotating talus impaction. Due to the intra-articular involvement, the pilon type should undergo fixation to achieve articular congruity, unlike the avulsion type whose function is only a secondary syndesmotic stabiliser.
The Use of Percutaneous Screw Fixation without Fracture Site Preparation in the Treatment of 5th Metatarsal Base Non-Union
Authors: Heyes Gavin , Grant Michael , Molloy Andrew P , Mason Lyndon W 
Published: October 2019

Category: Midfoot/Forefoot, Trauma Introduction/Purpose: Non-union following a proximal 5th metatarsal fracture can cause considerable pain with high morbidity with loss of work. Although many authors advocate early surgical management of zone 3 injuries (Jones fracture), zone 1 and 2 fractures are generally expected to heal with conservative management. Uncommonly, zone 1 and 2 fractures can develop non- unions. The aim of this study was to evaluate the efficacy of closed intramedullary screw fixation for non-unions of the 5th metatarsal base. Methods: We performed a prospective study involving all 5th metatarsal base non-unions treated in our department over 2 years. Only minimally-displaced adult fractures were considered for this study. The fracture pattern was categorised using the Dameron classification (zone 1 – styloid process, zone 2- meta-diaphyseal area, zone 3 – proximal diaphysis). All non-unions were fixed percutaneously under radiographic guidance, without fracture site preparation. Zone 1 injuries were fixed using a 3 mm headless compression screw and zone 2 and 3 with an intramedullary 4 mm screw. Results: Out of 30 patients included in this study, a minimum of 6 month clinical follow up was obtained. The average time from injury to treatment was 6 months (range 3-36 months). There were no smokers in this patient cohort. There were 12 zone 1 injuries, 9 zone 2 injuries and 9 zone 3 injuries. All patients achieved union by 3 months post screw fixation, with 29 out of 30 achieving union by 6 weeks. All patients had resolution of symptoms. There were no complications. Conclusion: We conclude that percutaneous fixation of 5th metatarsal base non-unions, without fracture site preparation, achieves excellent results. We believe that the screw alters the strain of the fracture, thus promoting fibrous to osseous conversion and therefore union.
Axial Rotational Alignment of Mobile-Bearing Total Ankle Arthroplasty
Authors: Hintermann Beat , Zwicky Lukas , Schweizer Christine , Barg Alexej , Ruiz Roxa 
Published: October 2019

Category: Ankle Arthritis Introduction/Purpose: In total ankle arthroplasty (TAA), component malpositioning is a major cause of implant failure, possibly due to the altered force patterns caused by the malpositioning which are then transmitted to the bone-implant interface or neighboring joints during physiological loading. Mobile-bearing TAA with their second interface, may allow the talus to adapt its position based upon the individual anatomy. However, no data exist on the change in component positioning after implantation. It is unclear whether it is the result of initial positioning during implantation or secondary adjustments such as possible soft tissue adaptions. We aimed to determine the relative axial rotation between the talar and tibial components at the end of surgery and after a minimum of 3 years follow-up. Methods: The relative rotation between the tibial and talar components was measured in two groups. First, intraoperatively before wound closure, in a consecutive series of 58 patients (60 ankles; age 61.8 [31 to 86] years; females 25, males, 35) who underwent TAA between February and November 2018. A K-wire inserted along the medial border of the tibial component and a rectangular marker positioned at the anterior surface of PE insert were used to determine the angle of rotation. Second, in 48 patients (48 ankles; age 60.2 [31 - 82] years; females, 24; males, 24) out of 1411 patients who underwent TAA between January 2003 and December 2015, and in whom a weight-bearing CT scan was taken for evaluation at 6.3 (range, 3.0 -16.3) years. The medial border of the tibial component and a perpendicular line to the anterior surface of the PE insert were used to determine the angle of rotation. Results: The angle of rotation, thus the relative position of the talar component compared to the tibial component, did not differ between the two groups (p = 0.2). While the talus was internally rotated by 1.7 (range, -14.0 - 14.0) degrees at the end of surgery, it was internally rotated by 1.5 (range, -13.0 – 19.5) degrees after a minimum follow-up of 3 years (Figure 1). Conclusion: Although there was no significant difference in average axial position measured intraoperatively compared to a 3- years follow-up, there was a wide range of rotational measurements. The possibility of the talar component to find its position as given by individual anatomy may be crucial in TAA to avoid non-physiological joint loads and shear forces which may otherwise result in increased PE wear. Due to the wide range of measurements, our data suggests that axial talar rotation cannot be predicted preoperatively or intraoperatively by surgical techniques that reference the transtibial axis, tibial tuberosity and transmalleolar axis as guidance for tibial component positioning.
InternalBrace Has Biomechanical Properties Comparable to Suture Button but Less Rigid than Screw in Ligamentous Lisfranc Model
Authors: Hopkins Justin , Nguyen Kevin , Heyrani Nasser , Shelton Trevor , Kreulen Christopher , Garcia-Nolen Tanya , Christiansen Blaine A. , Giza Eric 
Published: October 2019

Category: Midfoot/Forefoot, Trauma Introduction/Purpose: Lisfranc injuries occurring between the medial cuneiform and base of the 2nd metatarsal require anatomic fixation. Suture button and screws are standard techniques for fixation, but the screw may decrease physiologic motion, whereas suture buttons may cause increased soft tissue irritation and iatrogenic cartilage damage. Potential benefits of the InternalBrace include physiologic motion, decreased iatrogenic damage, collagen ingrowth, limited bony erosion and decreased soft tissue irritation. In light of these potential benefits, no studies have investigated the biomechanical properties of the InternalBrace in a Lisfranc injury model. However, it is unknown whether there is significant difference in the biomechanical properties of the IB compared to the screw, or SB during load to failure, and cyclical loading. Methods: Three groups of sawbones were fixed together with either a 3.5 mm screw, SB, or IB, composed of a curved button, fibertape, and 4.75 mm biotenodesis screw. Sawbone constructs were held in a mechanical testing system (Model 809, MTS Systems Corp, Minneapolis MN). The first three groups of 10 were loaded in axial tension at 0.5mm/sec until failure to determine load-displacement data. Yield, stiffness, ultimate strength (US), yield energy, post-yield energy and ultimate strength energy were calculated. Three more groups of 8 constructs were loaded in-vitro at cyclical physiologic loads until displacement of 1.5 mm occurred. Constructs were first loaded for 10,000 cycles at 69 N (estimate for 50% body weight or assisted walking). Surviving specimens were loaded at 138 N (normal walk) for an additional 10,000 cycles and then 207 N (jog) for an additional 10,000 cycles. Displacement was recorded. The biomechanical properties were then compared between groups. Results: When loaded in axial tension at 0.5mm/sec until failure, the screw was found to be the stiffest construct (2,240 N/mm), while the InternalBrace (200 N/mm) was stiffer than the suture button (133 N/mm). Qualitatively, the InternalBrace was also found to hold load more consistently and for larger displacement prior to failure when compared to the suture button. Cyclic loading was performed with 10,000 cycles of 69 N, 138 N, and 207 N. The screw had the greatest resistance to fatigue. The InternalBrace maintained stiffness as well or better than the suture button, but the fatigue life was shorter than that of the suture button. Conclusion: To our knowledge, the biomechanical properties of the IB have not been compared to screw and SB for ligamentous lisfranc injuries. This study gives valuable information about the mechanical integrity of InternalBrace and supports continued use. However, further studies are warranted before making conclusions regarding early weight bearing.
Review of Use of Amniotic Membrane Allograft in Total Ankle Replacements
Authors: Horn Andrew , Saller Jeremy , Cuttica Daniel , Neufeld Steven 
Published: October 2019

Category: Ankle Arthritis Introduction/Purpose: Wound complications after total ankle replacement (TAR) lead to increased postoperative morbidity with lasting consequences. Previous studies demonstrate delayed wound healing in 6.6% to 28% of all TARs. Soft tissue breakdown along the anterior incision can cause exposure of anterior tendons and the implants. In addition, adhesions of the extensor tendons can develop causing significant morbidity. Recent publications advocate for the use of dehydrated human amnion/chorion membrane allograft (dHACM) during closure of anterior ankle incisions during TAR. dHACM is shown to promote increased epithelial cell proliferation, recruitment, and differentiation and reduce the likelihood of tendon adhesions. The goal of this study was to review the use of dHACMs in TARs and to investigate the number and type of postoperative wound complications including extensor tendon adhesions. Methods: We retrospectively reviewed 92 TARs performed between April, 2016 through August, 2018 by two board certified, fellowship trained foot and ankle orthopaedic surgeons. A standard anterior approach was done in all cases. All TARs had dHACM graft placed deep to the tibialis anterior and extensor longus tendon and along the extensor retinaculum prior to final closure of the wound. Upon data review, we identified the subset of patients who had anterior wound dehiscence postoperatively requiring an additional procedure(s) for wound coverage. We compared the demographics, medical comorbidities, and operative characteristics of those with and without perioperative wound complications. Results: 12 patients who underwent TARs sustained wound dehiscence below the subcutaneous tissue and required operative intervention (13%). Of these 12 cases, 5 required bipedical or rotational fasciocutaneous flap coverage (5.4%), 6 required less extensive soft tissue surgery (6.5%) and one case involved a deep periprosthetic infection that resulted in explant and antibiotic spacer placement (1.1%). 6 of the 12 cases required a split thickness skin graft application (6.5%) and 2 cases required tenolysis of extensor tendon adhesions (2.2%). Normal excursion of extensor tendons was seen in 90 patients (97.8%). Except for the one infected ankle, there were no cases with wound dehiscence that communicated with the joint. There were no statistically significant differences in medical comorbidities/operative characteristics between patients with wound complications and those without. Conclusion: Wound complications after total ankle replacements often lead to poor long-term outcomes for patients. Our data suggests that the application of the amniotic membrane allograft and its inherent healing potential decreases postoperative tendon adhesions and significant wound dehiscence. This may lead to less deep wound infections that communicate with the joint and may be protective against total ankle replacement failures due to these complications.
Evaluating a Diagnostic Ankle Arthroscopy Scoring System to Assess Competency in Orthopaedic Trainees
Authors: Johnson Jeremiah D. , Schmidtberg Brian , Cheng Christopher , Cote Mark , Geaney Lauren 
Published: October 2019

Category: Arthroscopy Introduction/Purpose: While there has been an increasing emphasis on assessing resident competency, little has been published on how to best evaluate competency for ankle arthroscopy. The purpose of this study was to design and validate an objective model for assessing basic ankle arthroscopy knowledge and surgical skills on a cadaveric ankle. Methods: The Basic Ankle Arthroscopy Skills Scoring System was adapted from previously validated assessment tools for knee arthroscopy. The scoring system includes (1) an oral questionnaire (0-23 points), (2) a surgical task-specific checklist (0-19 points), and (3) a global surgical skills rating (12-60 points). Ten medical students and twenty-three residents participated. All participants performed a diagnostic ankle arthroscopy on a cadaveric ankle and were assessed by a single observer. Six participants were tested by two evaluators to determine inter-observer reliability. Results: There was strong correlation between educational level and scores on the global surgical skills rating scale (r=0.967, p<0.0001), task-specific checklist (r=0.815, p<0.815), and oral questionnaire (r=0.896, p<0.0001). The global surgical skills scores were significantly different over multiple trainee levels but most notably between post graduate year (PGY) 1 and 2 (p<0.01) and between PGY 2 and 3 (p<0.05) [Figure 1a]. Oral questionnaire and task-specific checklists were significantly lower for medical students than PGY1 residents (p<0.001) [Figure 1b-c]. There was significant improvement in the oral questionnaire between senior and junior residents (p<0.05). There was a moderate correlation between number of ankle arthroscopy cases and scores on the global surgical skills score (r=0.7019, p<0.0001). Inter-observer reliability was high for the global surgical skills scores (ICC=0.89). Conclusion: The Basic Ankle Arthroscopy Skills Scoring System is a valid measure to objectively assess trainees’ ankle arthroscopy clinical knowledge and surgical skills in a bioskills laboratory. This tool will allow residency programs to evaluate competency and track individual progress over time.
The Role of the Anterior Talofibular Ligament in Acquired Flat Foot Deformity and in the Operative Correction by Lateral Calcaneal Lengthening
Authors: Jud Lukas , Viehöfer Arnd , Singh Sarvpreet , Zimmermann Stefan , Götschi Tobias , Rigling Dominic , Wirth Stephan 
Published: October 2019

Category: Hindfoot Introduction/Purpose: Different factors are well known influencing the development of adult acquired flatfoot (AAF) deformity. So far less attention was paid to the lateral ligament complex. The idea that the anterior talofibular ligament (ATFL) probably influences AAF could be obvious concerning its anatomical course. Goal of this study is to assess the influence of ATFL on AAF and on operative AAF correction by lateral calcaneal. Methods: We reviewed all patients that undergone lateral calcaneal lengthening in AAF from 01/01/2008 to 07/31/2018 in our clinic. Patients were grouped in patients with intact ATFL and in those with injured ligament. Two independent readers performed assessment of common radiographic flatfoot parameters in preoperative and postoperative radiographs. Results: Statistical significant difference between two groups could be observed for preoperative talonavicular uncoverage angle (p=0.018) and talocalcaneal angle (p=0.032), with more severe AAF in patients with injured ATFL. The other common radiographic parameters showed no significant difference, although a tendency to a more severe AAF could be observed within the group with damaged ATFL. No difference could be observed in surgical outcome or consistency after lateral calcaneal lengthening between two groups. Conclusion: ATFL seems to take impact in AAF concerning talonavicular uncoverage angle and talocalcaneal angle. In patients undergoing lateral calcaneal lengthening the integrity of the ligament seems not to influence the degree of correction or the consistency of the postoperative result.
Can Combination of Peripheral Nerve Block and Non-opioidal Patient Controlled Analgesia Be an Effective Postoperative Pain Control Method?
Authors: Kang Chan , Lee Gi Soo , Kim Dong Yeol , Lee Jeong-kil , Ahn Ki Jun , Hwang Sung Jin , Seo Gang Won , Kim Yong Hwan , Lee Sang Bum , Song Jae Hwang 
Published: October 2019

Category: Ankle, Pain medicine Introduction/Purpose: Even though bone surgery is very painful after operation, there is no established method to control postoperative pain due to efficacy and side effects. Ultrasound-guided peripheral nerve block (PNB) and nonsteroidal anti- inflammatory drugs (NSAIDs) patient controlled analgesia (PCA) can effectively control pain and reduce side effects. Methods: We conducted a prospective study of 150 patients over 18 years of age who underwent bone surgery from June 2018 to December 2018. All operations were performed under anesthetic ultrasound-guided PNB and additional PNB was performed to control postoperative pain. Among the 120 patients who participated in the final study, NSAIDs PCA was used in group A (65 patients) and NSAIDs PCA was not used in group B (55 patients) for pain control. Postoperative management except PCA was same in both groups. Pain scores are measured at 6, 12, 18, 24, 36, 48, and 72 hours after the operation and they were compared using visual analogue scale (VAS) pain scores. Survey was done on satisfaction of patients, and their willingness to reconsider same method of pain control when they undergo same surgery next time. Also, we evaluated possible side effects that might happen during process of controlling pain. Results: VAS pain score were significantly different only at 24 h postoperatively (p=0.004). In Group A, three patients were prescribed 3 amples of pethidine intramuscular injection as rescue analgesic. In group B, 35 patients were prescribed 50 amples of pethidine and 12 patients of them were received additional 18 amples of ketorolac intramuscular injection as rescue analgesic(p=0.000). In group A, all patients were satisfied with the pain control method, but 5 of the group B patients were dissatisfied (p=0.001). 3 patients responded to severe pain after operation and 2 of them due to postoperative nausea and vomiting (PONV). In group A, there were no patients complaining of PONV, but in group B, 5 patients complained of symptoms (p=0.018), and 3 of them were prescribed additional antiemetics (p=0.093). Conclusion: Combined use of ultrasound-guided PNB and NSAIDs PCA seems to be an effective postoperative pain control method in foot and ankle surgery. Because, pain can be effectively controlled and PONV can be reduced.
Intraoperative Ultrasound Guided Percutaneous Repair of Ruptured Achilles Tendon: A Comparative Study with Open Repair
Authors: Kang Chan , Lee Gi Soo , Lee Jeong-kil , Ahn Ki Jun , Hwang Sung Jin , Lee Soong Hyun , Lee Sang Bum , Song Jae Hwang 
Published: October 2019

Category: Ankle, Trauma Introduction/Purpose: To compare and analyze the clinical outcomes between ultrasound guided percutaneous repair(USPR) and open repair in ruptured Achilles tendon. Methods: We retrospectively analyzed the outcomes between 12 patients with USPR (group A) and 18 patients with open repair (group B), from January 2015 to February 2018. The postoperative clinical evaluations were done by Arner-Lindholm scale, American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, Achilles tendon Total Rupture score (ATRS), visual analogue scale (VAS) for overall satisfaction and cosmetic satisfaction of scar, and starting time of single heel raise. And we evaluated complications. Results: There was no statistical difference between two groups in Arner-Lindholm scale, AOFAS score, ATRS, starting time of single heel raise (all p>.05). There was statistically higher overall patient’s satisfaction and cosmetic satisfaction in group A than group B (all p<.05). There were 2 cases of Achilles tendon elongation in group A, and 1 case of re-rupture with deep infection and 1 case of superficial infection in group B. Conclusion: The USPR showed not only good clinical outcomes but also high satisfaction and low rate of complications like sural nerve injury. Thus, it is thought that USPR can be considered as an effective surgical treatment options for Achilles tendon ruptures.