bluuebunny/crossref_metadata_2025_split huggingface dataset:
Novel Pathologic-Scoring for Charcot Arthropathy with Intraneural Observations
Authors: King Jesse , Murie Ben , Fanburg-Smith Julie , Stauch Chris , Walley Kempland , Flemming Donald , Aynardi Michael 
Published: October 2019

Category: Diabetes, Hindfoot, Midfoot/Forefoot Introduction/Purpose: Charcot arthropathy is a destructive joint disorder in patients with longstanding neuropathy, commonly related to Type II diabetes (T2DM). The diagnosis is historically classified via the radiologic Eichenholtz staging system (E-score). The purpose of this study is to examine histopathologic features and develop a correlative pathologic score for Charcot neuroarthropathy. Methods: Patients undergoing lower limb surgery with a clinical diagnosis of midfoot-ankle Charcot neuroarthropathy were included for study. Clinical data, radiology, E-score (1-3), and surgical pathology specimens were reviewed to evaluate skin, adipose, vessel, skeletal muscle, nerve, bone, and bone fragments embedded in synovium. Charcot pathology-score 1 (P-score, CPSI) = large bone fragments (> half 40x hpf objective) without host histiocytic response. CPSII = mixed large and small bone fragments with/without host histiocytic response, CPSIII = small to minute spicules to almost complete resorption/absence of bone fragments with histiocytic/fibrosis-reactive response, were scored by the authors in a blinded fashion. Results: Forty-two patients (32 males and 10 females) were included in analyses with a mean age of 59.9 years (median age: 60, range 28-83). Clinical risk factors for Charcot included T2DM and longstanding neuropathy. Elevated HbA1C, E-Score, preoperative American Society of Anesthesia score, and Charlson comorbidity index were predictors of amputation. Majority of pathologic specimens examined had superficial ischemic ulceration, dermal fibrosis, cellulitis, medial hypertrophy, atherosclerosis, skeletal muscle atrophy, and nerve hypertrophy with intraneural edema and perineural fibrosis. Osteomyelitis was present in >70%. P-scores CPSI = 6%, CPSII = 44%, CPSIII = 50% correlate with E-scores in 98% of cases without interobserver variability. Minor difference from E-score to P-score (2%) was due to sampling. Novel neuropathy change includes observation of intraneural vasculopathy (arteriolosclerosis) in evaluable nerves. Conclusion: CPS is reliable and reproducible and can be performed with adequate synovial sampling. Charcot progresses from large bone fragments in synovium to mixed size with histiocytic response, and final small/resorbed fragments with marked host response/fibrosis. Intraneural vasculopathy likely plays a role in Charcot. Charcot pathology-score (P-score) strongly correlates with clinicoradiologic Eichenholtz-score (E-score).
Retrospective Analysis of the Reverdin-Green Osteotomy for Hallux Rigidus in the Presence of Metatarsus Primus Elevatus
Authors: Krause Fabian , Rueger Tobias , Alpuerto Bernadino 
Published: October 2019

Category: Bunion Introduction/Purpose: Hallux rigidus outlines progressive degenerative changes in the 1st metatarsophalangeal joint (MTP I) by several causative factors, i.e. metatarsus primus elevatus. It often leads to disability, difficulties wearing shoes, and gait abnormalities. Despite numerous non-operative and surgical treatments for hallux rigidus reported in the literature, a gold standard treatment protocol for the disease is still missing. Thus, this study investigates the clinical and radiographic outcomes of the commonly used Reverdin-Green Osteotomy (RGO) by validated outcome measurements. Methods: We retrospectively reviewed medical records of ten patients (12 feet) that were diagnosed with hallux rigidus in the presence of metatarsus primus elevatus (MPE) and underwent RGO procedure. Primary study objective was the clinical outcomes of the RGO procedure, among others measured by validated FFI and SF12 scores. Secondary study objective was to determine any progression of MTP1 arthritis after the procedure. Results: The average 1st MTP dorsiflexion had improved from 39° (SD ± 21°) to 54° (SD ± 17°). The average value of the AOFAS, hallux metatarsophalangeal-interphalangeal subscale was 81 points (±9.5). The FFI, revealed an average score of 27.5 (± 18.7). The VAS-FA was 70.5 (± 19) for pain, 77.7 (± 23) for function. In the SF-12 survey, the general physical health score was 73 (± 19) and the general mental health score 76 (± 14) on average. Only one patient demonstrated a radiological progression of MTP joint degeneration from grade 2 to grade 3. In all other cases, arthritis grading remained stable. A MPE of equal or more than 5 mm was present (mean 6.9, SD ± 1.7) in all feet. Conclusion: In the presence of supposedly causative MPE, the RGO seems to be a reasonable option. To determine the most appropriate surgical solution for treatment of specific stages of hallux rigidus, long-term follow-up and further studies are necessary in the future.
Evaluation of Anatomic Relationship between Sural Nerve and Instrumentation during Mini-open Achilles Tendon Repair: A Cadaveric Study
Authors: Krautmann Kurt M. , Stewart Gary W. 
Published: October 2019

Category: Sports Introduction/Purpose: The Achilles tendon is one of the most commonly ruptured tendons in the adult population, and there is still no consensus on optimal treatment. While surgical repair may result in a lower re-rupture rate and quicker functional return, it also comes with risk of wound complications and sural nerve injury. If surgical repair is chosen, the surgeon may choose a traditional open procedure, a mini-open technique, or a percutaneous approach. The main advantage of the mini open repair method is the reduced wound complications that comes with a much smaller incision, while still maintaining similar re-rupture rates. The purpose of this study was to determine the relationship of the sural nerve to the Arthrex PARS jig and repair sutures. Methods: Cadaveric dissection was performed on 10 unpaired above knee amputation specimens. After severing the Achilles tendon and inserting the jig for a mini open repair, the sural nerve was dissected out to determine the rate of nerve puncture by the passed sutures. The jig was then removed to determine if the nerve was bound by the passing sutures or wrapped during suture locking. Results: The sural nerve was punctured 9 times out of the total of 50 sutures passed for an 18% puncture rate. All 9 punctures occurred in 4 specimens (Image 1), with the remaining 6 cadavers sustaining no punctures. Of the 6 unpunctured cadavers, 5 had all sutures passing anterior to the sural nerve, but in close proximity. One cadaver had all sutures passing posterior to the sural nerve. In all cadavers, removal of the jig and locking of the sutures left the sural nerve free with the sutures well fixed within the Achilles tendon. The sural nerve was also found to be within 1 cm of the lateral edge of the mini-open transverse incision in all cadavers. Conclusion: The Arthrex PARS jig was successful in preventing binding of the sural nerve during mini-open Achilles repair, but the sutures are often passed directly through the nerve during the procedure. The sural nerve is also at risk at the lateral edge of the mini-open incision used to insert the jig, and must be carefully protected during dissection down to the tendon.
High Prevalence of Poor Sleep Quality in Chronic Foot and Ankle Conditions
Authors: Kunze Kyle N. , Wu Kevin , Wakefield Connor , Bohl Daniel D. , Holmes George B. , Lin Johnny , Lee Simon , Hamid Kamran S. 
Published: October 2019

Category: Ankle, Hindfoot, Midfoot/Forefoot Introduction/Purpose: Sleep disturbance is a known risk factor for poor healing and is associated with medical co-morbidities. Poor sleep quality is also a common complaint of pre-operative patients; yet, there remains a paucity of investigations in this realm. The purpose of this study is to quantify the prevalence of sleep disturbance in patients undergoing surgical management of chronic foot and ankle conditions. Methods: Patients scheduled for first-time surgical management of a chronic foot and ankle condition were identified between May and November of 2018 at a tertiary care medical center. Patients with a known sleep disorder or refusal to participate were excluded. Of 139 patients initially identified, 84 (60.4%) were included and administered the Pittsburgh Sleep Quality Index (PSQI) pre-operatively. The PSQI ranges from 0-21, with a score ±5 indicative of poor sleep quality. Patients were also asked to rate their perception of how their foot or ankle pain influenced their sleep quality on a scale of 0-10 (foot ankle pain perception score, FAPPS). A multivariate linear regression model was used to determine predictors of sleep disturbance. Results: The mean (+/- standard deviation) age of the 84 included patients was 48.2+/-13.8 years; body mass index (BMI) was 28.9+/-5.0 kg/m2; 52.4% of patients identified as male; and conditions and treatments were varied (Table 1). The mean PSQI score was 7.6+/-4.3 (range, 2-21) and mean FAPPS was 3.2+/-2.7. A total of 64 (76.2%) patients had a PSQI score greater than/equal to 5, indicating presence of sleep disturbance. A total of 68 (81.0%) patients had a FAPPS greater than/equal to 1, indicating that a patient perceived that their foot or ankle pain contributed to sleep disturbance. Age, sex, BMI, and condition/treatment category were not correlated with PSQI score (p>0.05 for each); however, greater FAPPS was an independent predictor of a greater PSQI score (p<0.001). Conclusion: Patients presenting for management of chronic foot and ankle conditions have a high prevalence of sleep disturbance pre-operatively. The majority of these patients perceive their foot and ankle conditions to significantly contribute to their sleep disturbance. Further testing assessing post-operative changes to sleep quality is warranted.
Hypertrophic Syndesmotic Impingement and Its Effect on the Ankle Joint
Authors: Kwon Jae Bum , Kim Sungjun , Hong Seung-pyo , Lee Jin Woo , Han Seung Hwan 
Published: October 2019

Category: Ankle, Arthroscopy Introduction/Purpose: During ankle arthroscopic surgery, chronic syndesmotic instability is a common combined finding of ankle instability and induces the development of a hypertrophic synovial fold. This pathologic lesion protrudes into the ankle joint cavity in various tissue types, such and hypertrophied synovium, fat or fibrosis. However, the effect of this impingement tissue on the ankle joint and the associated clinical significance have not been well-evaluated. This study aimed to identify the histological type of the syndesmotic impingement tissue and analyze its effect on the lateral talar dome cartilage, in addition to the clinical correlation with the tissue type. Methods: A total of 62 patients (64 ankles) with chronic ankle instability and syndesmotic impingement who underwent arthroscopic surgical management from January 2017 to June 2018 were enrolled in this study. During arthroscopic surgery, we visually classified the hypertrophic syndesmotic tissue and performed biopsy. We also evaluated the prevalence of cartilage lesions at the lateral talar dome with its location. The association between the duration of symptoms and tissue diagnosis was also evaluated. Results: Based on the pathologic results, 4 samples with fat degeneration, 37 samples with fibrosis, 7 samples with synovial hypertrophy, 12 samples showing mixed type hypertrophy, and 4 samples with other type of hypertrophy were identified. Among the 64 cases, articular cartilage lesions at the lateral talar dome were present in 15 cases. In 10 of 15 cases, the pathologic results revealed the presence of fibrous tissue, while 5 cases of other type including synovial hypertrophy, were identified. In 13 cases, the cartilage lesions were located in the middle third of the lateral talar dome. The patients experienced ankle joint instability for 35.5 ± 33.7 months. Longer duration (>24 months) of instability was associated with a higher rate (81.8%) of fibrotic change in the syndesmosis. Conclusion: Repetitive syndesmotic impingement can cause hypertrophic synovial changes; the hypertrophic synovial tissue may evolve into fibrotic impingement tissue as the duration of symptom persistence increases. If the hypertrophic tissues are fibrotic, they may be harder in terms of physical properties and may cause the development of cartilage lesions at the talar dome due to the repetitive load. Considering our results, prophylactic debridement may be effective to prevent the development of cartilage lesions at the talar dome, when hypertrophic tissues are observed during arthroscopic surgeries.
Syndesmotic Implant Removal: Does It Really Improve Ankle Dorsiflexion Range of Motion?
Authors: Kwon John Y. , Wusu Timilien , Briceno Jorge , Kaiser Philip , Cronin Patrick , Leblanc Alyssa , Velasco Brian , Miller Christopher 
Published: October 2019

Category: Ankle Introduction/Purpose: There is limited evidence that removal of syndesmotic implants is beneficial. Despite this, many surgeons advocate removal based on previous studies suggesting improved ankle dorsiflexion. Methodologic difficulties make the validity and applicability of previous works questionable. The purpose of this study was to examine the effect of ankle dorsiflexion after syndesmotic implant removal using radiographic measurements of ankle dorsiflexion before and after screw removal utilizing a standardized, applied load. Methods: All patients undergoing isolated syndesmotic implant removal were consented for participation. Ankle dorsiflexion was measured radiographically at three different time points: (I) immediately before implant removal intraoperatively, (II) immediately after implant removal intraoperatively and (III) approximately three months after implant removal. A standardized dorsiflexion torque force of 33.4 newton-meter (Nm) was applied to the ankle by a research assistant using a tensiometer at these time points and a perfect lateral radiograph of the ankle was obtained. Four reviewers independently measured ankle dorsiflexion on randomized, deidentified and blinded images using a digital measurement tool. Chi-square tests were used for categorical variables. Paired T-test or analysis of variance (ANOVA) with repeated measures was used for continuous variables. Intra-class correlation coefficients (ICC) were calculated using a 2-way random effects model and the absolute agreement definition. Results: 29 patients met inclusion criteria and were enrolled in the study. There were 11 men (38%) and 18 women (62%). The mean, and standard deviation, age was 50.3 ± 16.9 years (range 19-80). The mean ankle dorsiflexion pre-operatively, post-op and at 3 month follow up was 13.7°± 6.6°, 13.3°±7.3° and 11.8°±11.3°, respectively (p=0.466). For subsequent analysis, 5 patients were excluded due to potential cofounding effect of retained suture button devices. Analysis of the remaining 24 patients demonstrated similar results with no statistically significant difference in ankle dorsiflexion at all three time points. Conclusion: Removal of syndesmotic screws does not improve ankle dorsiflexion motion and should not be used as an indication for screw removal.
Outcomes Following Calcaneal Autograft with a Reaming Graft Harvester
Authors: Langan Travis M. , Consul Devon , Law Rona , Hyer Christopher F. 
Published: October 2019

Category: Hindfoot Introduction/Purpose: Autogenous bone graft remains the standard bone graft in foot and ankle surgery when filling a bone void or adding biology to an arthrodesis site. Harvesting autograft can have serious donor site morbidity with an average complication rate of 8% and reports as high as 25%. Complications range from persistent pain to severe infection. Most procedures in the foot and ankle require only a small volume of graft. Using a small reaming graft harvester, surgeons can harvest autograft from the ipsilateral calcaneus. This is done within the same surgical field and requires minimal additional operative time. The purpose of this article is to review a population of patients who underwent calcaneal autograft harvesting with a reaming graft harvester and evaluate the outcomes of the procedure. Methods: From August 2015 to February 2018, all patients who underwent calcaneal autograft harvesting by a single surgeon were identified and reviewed. Patients were included if they had autograft harvested from the calcaneus on the ipsilateral operative limb using a reamer bone graft harvester and if they had complete clinical follow up of at least 6 months. Patients were excluded if they had autograft from a site other than the ipsilateral calcaneus, had a previous harvest from the ipsilateral calcaneus, or if they did not have full follow up of at least 6 months. Outcomes of interest were major and minor complications, intra- operative complications, and long term radiographic findings. Patients required graft for numerous primary procedures including a variety of arthrodesis or filling of bone voids. Postoperative protocols and return to weightbearing times varied with the accepted protocols for the primary procedure. Results: 300 patients were identified and met inclusion criteria. Average follow up was 12.6 months. There was 1 major complication (0.3%) consisting of a calcaneal stress fracture that healed with a period of 4 weeks of non weightbearing followed by 4 weeks of protected weightbearing. There were 3 minor complications (1%) consisting of transient painful scar and medial heel pain that all resolved uneventfully. There were no intraoperative complications while performing the 300 procedures. There were no incidences of neurovascular damage. Of the patients with over 1 year radiographic follow up, all harvest sites were still visible on lateral plain film radiographs. Conclusion: Using a small reamer to harvest calcaneal autograft for foot and ankle surgeries that require a small to moderate amount of bone graft is safe and effective. Approximately 4 cc of graft can be harvested very quickly without needing to prepare another surgical site for harvesting. The complication rate for harvesting calcaneal autograft was found to be extremely low in this study, despite the harvest site remaining visible on radiographs past 1 year. The proposed technique can be extremely useful to the foot and ankle surgeon.
The Clinical, Radiologic Outcomes of Indirect Anteroposterior Screw Fixation for Posterior Malleolar Fracture in Rotational Ankle Fractures: Comparison with Syndesmosis Fixation
Authors: Lee Sunghyun , Kwon Hoiyoung 
Published: October 2019

Category: Ankle Introduction/Purpose: The posterior malleolus is an important soft tissue attachment for the posterior inferior syndesmosis ligament. Recent studies suggested that direct fixation of a sizable posterior malleolar (PM) fracture through posterolateral approach would act to stabilize the syndesmosis and minimize or eliminate the need for trans-syndesmotic fixation. Indirect anteroposterior (AP) screw fixation was an alternative method, which represent relatively low complication. However, there were few studies to evaluate the stability of syndesmosis after indirect anteroposterior screw. The purpose of this study was to define the rate of syndesmotic instability after anteroposterior screw fixation and to compare to the clinical and anatomical outcomes with indirect reduction without fixation. Methods: We performed a retrospective review between 2009 and 2015 of consecutive patients who underwent surgery with sustained rotational ankle fractures including PM fractures. The exclusion criteria included age <18 years, diabetic neuropathy, tibial pilon fractures, previous ankle fracture repair and not available at minimum 1 year follow up. After the fibula and medial malleolar fracture fixation, the PM was fixed with an AP screw, leaving some of relatively smaller and indirect reduced PM fractures unfixed. Patients were sorted into 2 groups according to the presence (group F) or absence (group N) of AP screw fixation of PM. Then, both groups were divided according to the intraoperative necessity of syndesmotic fixation. The demographics, PM fragment size and syndesmosis widening comparing intact ankle on CT at 1 year postoperatively were recorded for each fracture. The functional outcomes were assessed with the Foot and Ankle Outcome Score (FAOS). Results: A total 126 patients met the study inclusion criteria and underwent analysis. Syndesmotic fixation was required in 17 of 78 (21.8%) and 24 of 88 (72.7%) in group F and N, respectively (p=0.012). Postoperative and follow-up FAOS scores were similar in the four subgroups. The tibiofibular distance on CT was greater in the patients without syndesmotic screw fixation in group F and N (p=0.036 and 0.021, respectively). Conclusion: Indirect AP screw fixation of the PM fracture in rotational ankle fractures might be support syndesmotic stability and, thus, lower the rate of syndesmotic fixation. Also, these patients have functional outcomes at least equivalent to outcomes for patients having syndesmotic screw fixation. However, in AP screw fixation group, syndesmosis widening was evaluated without syndesmosis fixation, which could be resulted in degenerative arthritis change. Therefore, our data demonstrate that indirect AP screw fixation of PM fracture alone could not restore syndesmotic stability perfectly.