bluuebunny/crossref_metadata_2025_split huggingface dataset:
Association Between Syndesmotic Stability and Fracture Patterns of Lateral Malleolus After Supination-External Rotation-Type Ankle Fractures
Authors: Chun Dong-il , Yi Young , Won Sunghun , Cho Jaeho , Kim Ja-hyung 
Published: October 2019

Category: Ankle, Trauma Introduction/Purpose: Syndesmotic injury with supination-external rotation (SER)-type ankle fractures are well known for the serious damages to the osseous and soft tissue envelope. However, the Lauge-Hansen classification system does not provide sufficient information related to syndesmotic injury. In this study, we aimed to investigate factors for preoperative detection of syndesmotic injury according to fracture patterns in SER III and IV ankle fractures by using radiography and computed tomography (CT). Methods: All operative SER III and IV ankle fractures treated by a single surgeon from 2009 to 2015 were enrolled in a retrospective database. Based on computed tomographic evidence and intra-operative cotton test, two groups of the ankle factures were divided(stable and unstable). And .2%). Medial space widening and fragment angle of the fibular posterior cortex were measured (Figure1). Results: A total of 52 patients with SER III, 75 patients with SER IV, and 27 patients with SER IV equivalent ankle fractures were identified, with 106 in the unstable syndesmosis group (68.8%) and 48 patients in the stable syndesmosis group (31.2%). Medial space widening and fragment angle of the fibular posterior cortex were significant predictors(p<0.01, p<0.01, respectively). The cutoff values of these factors were 4.4 mm and 32.8 degrees, respectively (Figure2). Conclusion: In predicting syndesmotic injury at the preoperative period in SER-type III and IV, medial clear space widening and fragment angle of the fibular posterior cortex showed significant correlations. In particular, sharper fragment angle of the posterior cortex indicated higher probability of instability that remained after fracture fixation.
The Influence of Calcaneal and First Ray Osteotomies on the Contact Pressures of the Ankle Joint
Authors: de Cesar Netto Cesar , Zhengyu Gao , Abbasi Pooyan , Smyth Niall , Casscells Nicholas D , Michnick Stuart , Demetracopoulos Constantine , Parks Brent , Miller Stuart 
Published: October 2019

Category: Ankle, Hindfoot Introduction/Purpose: Medial displacement calcaneal osteotomies (MDCO) and first ray plantarflexion osteotomies, such as a Cotton osteotomy, are frequently used realignment procedures for hindfoot and ankle joint valgus malalignment. Multiple studies demonstrated the effects of calcaneal osteotomies on the contact pressures of the ankle joint (CPAJ), with slight medial displacement of the center of pressure and lateral unloading of the ankle joint. However, the influence of a first ray plantarflexion osteotomy on the CPAJ is yet to be determined. In this cadaveric study we compared the effects of calcaneal and first ray osteotomies in the CPAJ. Methods: Fifteen bellow-knee cadaveric specimens were dissected to expose the ankle joint and isolate the flexor and peroneal tendons. Tekscan 5033 sensors were placed in the ankle joint and held in place with cyanoacrylate. Specimens were loaded in a servohydraulic load frame. The following loads were applied to the tendons: Achilles (200 N), PTT (40 N), peroneals combined (44 N), FHL/FDL combined (35 N). Ankles were tested in an intact position, after isolated MDCO (6, 8, 10 and 12 mm), isolated Cotton osteotomies (4, 8 and 12 mm) as well as combined osteotomies (10 mm and 12 mm, respectively). Specimens were then cyclically load from 100N-700 N at a rate of 0.5 Hz for 30 cycles while CPAJ data was collected at a rate of 20 Hz. Average and maximum pressure data were extracted as well as the center of pressure (CoP) movement in the AP and ML directions. Results: There was a significant (p<0.05) and progressive decrease in respective maximum and average contact pressures of the ankle joint when comparing intact ankle (1608 and 1312kPa), calcaneal osteotomy (1291 and 1034 kPa), Cotton osteotomy (1165 and 962 kPa) and combined osteotomies (1134 and 903 kPa). Cotton osteotomy and combined osteotomies showed similar contact pressures. Regarding CoP measurements of the ankle joint, native ankle and MDCO demonstrated similar positionings in the sagittal and coronal planes. Cotton and combined osteotomies caused a significant shift of the CoP anteriorly and laterally when compared respectively to the intact/MDCO and MDCO ankles. Conclusion: The results of this study demonstrate that the Cotton osteotomy has a greater effect on the contact pressures of the ankle when compared to the MDCO. There is an overall decrease in the maximum and average pressures as well as a deviation of the center of pressure toward the anterior and lateral aspect of the ankle joint. These findings should guide surgeons when deciding between first ray and calcaneal osteotomies as realignment procedures for hindfoot and ankle valgus deformities.
The Role of Gender and Attire in Patient Perception of Foot and Ankle Physicians
Authors: Farber Daniel C. , Eilberg Brandon , Basatski Aliaksei 
Published: October 2019

Category: Patient Care Introduction/Purpose: Initial impressions between physician and patient typically occur through the medium of attire and potentially gender and can significantly impact the comfort and trust of patients in the clinical setting. The influence that foot and ankle orthopaedic physicians have on their patient’s footwear choices is of particular importance because it potentially affects clinical outcomes. Unlike other specialties where physician appearance or gender serves as a basis for mere initial perception, the nature of foot & ankle orthopedics allows for direct influence on a component of their care. The purpose of this study was to examine whether orthopedic physicians may serve as role models for healthy behavior and to elucidate the influence of patient perception on their orthopedic-related decision making. Methods: In this prospective, cross-sectional study, individuals =18 years of age that had the ability to make their own footwear decisions were invited to participate. Study subjects completed a 22-question survey following their office visit with one of four foot and ankle surgeons (2 female, 2 male). Quantitative assessment included: demographic data, the level of perception and attention given to their physician’s shoe choices, and various factors that affect decision making process when purchasing orthopedic-related footwear. Chi-square analysis was used to evaluate the categorical variables. Results: A total of 250 patients completed the study, with a normal distribution of ages between 18-81. 62% (n=154) had seen their physician multiple times and the remaining were new patients. Female patients preferred using recommendations from same- sex surgeons (41%) much more than males (6%). However, given the option of combining male/female opinions, 45% of females chose that option whereas 72% of males preferred combing male/female physician opinions when deciding on footwear. A sizable minority of patients noticed the type of shoe their physician was wearing that day, 32% (n=81). 52% (n=130) agreed that a surgeon’s own shoe choices should reflect the desirable attributes of a shoe. Patients ranked the shoe feel (51%) and their doctor’s recommendations (28%) as the top factors when deciding shoe-wear. Conclusion: Our study indicates that a significant portion of patients are mindful about and do consider their physician’s gender as well as physical appearance including shoe choices. While this influence was greater for females, patient footwear choices are affected across most demographics. The impact of patients’ awareness on medical action indicates that perception of care may hold significant value. Identifying the factors that influence orthopaedic decision-making can aid in accurately targeting patient education, enhancing physician-patient interactions, and improving clinical outcomes.
Radiographic Evaluation of Adult Acquired Flatfoot Correction with Augmented Spring Ligament Repair
Authors: Fogleman Jason , Kreulen Christopher , Sarcon Aida , Michelier Patrick , Swafford Rachel , Giza Eric , Doty Jesse 
Published: October 2019

Category: Flatfoot reconstruction Introduction/Purpose: Adult acquired flatfoot often results from posterior tibial tendon dysfunction followed by attenuation of the ligamentous support of the medial longitudinal arch of the foot. The spring ligament is the strongest ligamentous support for the talonavicular joint making it a viable target for flatfoot reconstruction procedures. There are concerns that direct repair of the spring ligament complex could result in failure as the already attenuated tissues of the ligament stretch out with mobilization and weight bearing. Suture tape augmentation of ligament repairs has shown greater loads to failure in biomechanical testing; however, there is a paucity of data surrounding clinical and radiographic outcomes of flatfoot reconstruction with augmented spring ligament repair. Methods: A retrospective review was performed of patients who underwent flatfoot reconstruction including spring ligament repair with suture tape augmentation between July 2014 and August 2017. Weight bearing radiographs were obtained for all patients both pre-operatively and at their last available follow-up. All radiographs were assessed by two surgeons for validated radiographic parameters including AP talocalcaneal angle, AP talo-first metatarsal angle, AP talar uncoverage, lateral talocalcaneal angle, lateral talo-first metatarsal (Meary) angle, lateral medial cuneiform-fifth metatarsal height, and lateral calcaneal pitch. Paired sample T-tests were used to compare pre-operative and post-operative radiographic measurements to assess for correction of these parameters. Results: 57 patients met inclusion criteria. The average time to final radiographic evaluation was 47 weeks (10 to 200 weeks). All radiographic parameters assessed showed significant correction when compared to pre-operative measurements. The average correction for each parameter included 6.02 degrees for AP talocalcaneal angle (p<0.001), 10.96 degrees for AP talo-first metatarsal angle (p<0.001), 12.65% for AP talar uncoverage percentage (p<0.001), 4.27 degrees for lateral talocalcaneal angle (p<0.001), 11.35 degrees for lateral talo-first metatarsal (Meary) angle (p<0.001), 8.31 mm for lateral medial cuneiform-fifth metatarsal height (p<0.001), and 2.91 degrees for lateral calcaneal pitch (p<0.001). Post-operative complications occurred in 5 patients. Conclusion: Reconstruction of adult acquired flatfoot with spring ligament repair using suture tape augmentation is a safe procedure that resulted in significant weight bearing radiographic correction at an average of 47 weeks follow-up.
A Clinical Sign for Diagnosis of the Hypermobile First Ray
Authors: Foong Weisheng , Rikhraj Inderjeet Singh 
Published: October 2019

Category: Midfoot/Forefoot Introduction/Purpose: The aim of this study is to describe a new clinical sign for diagnosis of hypermobility of the first tarsometatarsal joint (TMTJ). We propose a method of qualifying and quantifying the degree of hypermobility of the first tarsometatarsal joint which is easily reproducible and does not require the use of specific medical devices. Methods: 23 patients were examined and graded positive for hypermobility of the first ray by a heterogenous group of doctors using this method. This clinical sign of hypermobility of the 1st tarsometatarsal joint is then quantified by measuring the amount of dorsal displacement using a bedside ruler. All patients underwent Lapidus procedure for fusion of the 1st tarsometatarsal joint. Clinical results are documented at 2 years post surgery. Results: All 23 patients diagnosed with hypermobility of the first ray had a mean dorsal displacement of 7.95 ± 0.20 mm. Clinical results showed significant improvement in visual analogue scores and AOFAS scores at 2 years. Conclusion: Diagnosis of the hypermobility of the first ray can be made clinically using this easily reproducible method. The degree of subluxation of the 1st tarsometatarsal joint can be quantified without the use of cumbersome medical equipment.
An Intra-Operative Assessment of the Axial Rotational Positioning of the Tibial Component Using Patient-Specific Instrumentation Prophecy
Authors: Gagne Oliver J. , Veljkovic Andrea , Townshend Dave , Younger Alastair S.E. , Wing Kevin J. , Penner Murray J. 
Published: October 2019

Category: Ankle, Ankle Arthritis Introduction/Purpose: Ankle replacements (TAR) have evolved significantly over the past 10 years. While most TAR systems reference the medial gutter to set axial tibial component rotation, newer CT scan-based patient specific instrumentation (PSI) allows any rotational position to be set, and this is commonly set to bisect the medial and lateral gutter lines. It is still not yet known which alignment technique is optimal. Methods: We initiated a prospective cohort analysis of 22 consecutive cases using the Prophecy® 3D PSI guide (Wright Medical Technologies, Memphis, TN). There were four foot and ankle fellowship trained surgeons practicing from two referral centers. Every procedure had an intra-operative photograph taken from the knee looking down to the ankle after both the attachment of the PSI guide to the tibia and the insertion of the standard medial gutter fork. The axial rotational angle between both was measured and compared to the Prophecy® pre-operative plan. Statistical analysis was performed using the student’s T-test for paired distribution and descriptive statistics given the number of cases (N=22). Results: The primary outcome of this study was to assess the correlation between the pre-operative medial gutter line drawn on the Prophecy plan and the intra-operative medial gutter fork angle. The Pearson R correlation value was 0.54 (p = 0.53). The average difference between the pre-operative medial gutter line on the Prophecy® plan and the intra-operative gutter fork was -0.46 [95% CI -2.04 – 1.10]. This could mean that the medial gutter fork is on average slightly more internally rotated than templated medial gutter line. However, the average of the absolute differences between the preoperative medial gutter line and the intraoperative medial gutter fork was 2.69 degrees. Of the 22 cases, 11 were within 2 degrees and 17 were within 4 degrees. Conclusion: The medial gutter line on Prophecy® PSI pre-operative TAR plans is a moderately good representation of the intra- operative medial gutter fork position used in standard TAR instrumentation. Based on this, using the Prophecy® default which sets the tibial implant axial rotation to bisect the medial and lateral gutter lines will typically lead to greater external rotation of the tibial component compared to standard TAR instrumentation which aligns the tibial component to the medial gutter fork. Further work needs to be done to better understand which of these axial alignment options, or potentially others, is optimal.
Minimal Invasive Mid-Calf Gastrocnemius Recession: Safety and Efficacy Analysis
Authors: Gaitan Laura , Lopez Valeria , Calvi Juan Pablo , Alvarez Victoria , Slullitel Gaston 
Published: October 2019

Category: Midfoot/Forefoot Introduction/Purpose: Limited ankle dorsiflexion associated with an isolated gastrocnemius contracture is one of the key impairments present in some chronic foot and ankle pathologies. The Baumann procedure consists of a gastrocnemius recession through an incision along the proximal medial calf performed in the interval between the gastrocnemius and soleus fascia. The advantages of the technique is that isolates the lengthening to the gastrocnemius muscle and preserves muscle strength. It is performed in supine decubitus, making unnecessary to switch position of the patient. We performed it in a minimally invasive fashion through a 4 cm approach. Our purpose was to evaluate the functional results and satisfaction of patients after performing a release of the gastrocnemius through the Baumann minimally invasive procedure in different foot and ankle pathologies. Methods: 34 patients (37 procedures) whom presented with forefoot or midfoot or rearfoot pathologies that were suspected to be associated with gastrocnemius contracture between 2015 and 2017 were retrospectively evaluated (Table 1). All patient demographic information; such as age, sex, diagnosis and date of surgical, was retrieved from clinical charts. Patients included were to have an isolated gastrocnemius contracture as determined by a positive Silfverskiold test. Patients underwent Bauman gastrocnemius recession alone or in combination with other procedures according to each patient´s primary diagnosis. A supervised physical therapy program that consisted on stretching and flexibility of the posterior chain, was started as soon as possible depending on the underlying pathology, when possible, during the first postoperative week. Results: Thirty-seven procedures belonging to thirty-four patients were included in this investigation. The mean age of the patients was 47.13 years (range 26-78 years). The mean follow-up was 21.6 months (range 7-42 months). The average initial amount of ankle dorsiflexion measured was 108 (range 95 to 120) degrees. After gastrocnemius muscle recession, the average ankle dorsiflexion measured was 91 (range 84 to 95) degrees. Therefore, an overall improvement of 17 degrees was obtained. There were significant differences in the dorsiflexion angle measured pre and post-surgery (p < 0.05). 88.9% of the patients were satisfied and would undergo the same surgery if necessary. 91.7% would recommend the procedure to a friend or family member. Conclusion: There exists reasonably convincing evidence to support the use of gastrocnemius recession as a therapeutic intervention for isolated foot pain associated with an overload syndrome, justifying a grade of recommendation B. It is our perspective that the Bauman procedure offers a chance to lengthen the musculotendinous unit in a predictable manner, through a small incision avoiding the potential risks of over lengthening the gastrocnemius-soleus complex.
Hindfoot Alignment after Total Ankle Replacement
Authors: Gross Christopher , Manzi Luigi , Indino Cristian , Romano Fausto , Maccario Camilla , Usuelli Federico Giuseppe 
Published: October 2019

Category: Ankle, Ankle Arthritis Introduction/Purpose: End-stage ankle arthritis can involve misalignment of the ankle in both the coronal and sagittal planes as up to reported 33% to 44% of patients who present for total ankle replacement have greater than 10° of coronal plane deformity. Normalization of the sagittal and coronal alignment is key in improving survivorship and functional outcomes in TAR. In the present study, we analyzed how both the ankle and hindfoot alignment for both a fixed-bearing and mobile bearing TAR system changes over time. Specifically, we measured coronal and sagittal alignment of both the ankle and hindfoot complex. We hypothesize that both significant differences would be seen between all time points and pre-operative radiographs, and that these differences would not change over time. Methods: A retrospective study performed by a single orthopaedic surgeon was performed on two independent groups of patients undergoing two different systems for total ankle replacement: Zimmer TAR (lateral-approach, fixed-bearing, n=89) and Hintegra (anterior approach, mobile-bearing, n=81). We noted specific demographic data and radiographic data were measured including: Hindfoot alignment view angle (HAV), Hindfoot alignment distance (HAVD), tibiotalar ratio, a angle and ß angle. These were measured pre-operatively, and 6 months, 12 months, and 24 months post-operatively. Within-group comparisons were performed using one-way repeated-measures ANOVA (1-w rANOVA), analyzing temporal course of clinical data (comparisons between different time points, e.g. T0vsT6vsT12vsT24) within the Hintegra and Zimmer groups. To compare the time course of clinical measures between the two groups, 2-w rANOVAs were performed for SA, SD, TT ratio, a and ß angle. Specifically, time*group interaction was tested. Results: At the ankle joint itself, as measured by the a and ß angles (p>.05), the position of the components remains relatively similar in both the fixed and mobile bearing TAR over the course of 24 months. The sagittal alignment, as measured by the TT ratio, demonstrated a posterior shifting of the talus in the mobile bearing group (p=.036). Though the fixed and mobile-bearing TARhad both significant hindfoot alignment improvement between the pre-op radiographs and twenty-four months, over time, the fixed-bearing ankle had a significant increase in both the HAV and HAVD (p<.001), suggesting a dynamism of the hindfoot in the fixed-bearing ankle. Conclusion: Correcting coronal and sagittal alignment is important for the long-term survivorship of a TAR. The fixed and mobile-bearing implants had maintained coronal and sagittal alignment in the short term, the temporal course of the fixed-bearing ankle showed an increased in the valgus positioning of the hindfoot. The mobile-bearing implant maintained its hindfoot alignment over the course of the study. More studies are needed to explore the clinical implications of this new data.
Clinical Evaluation and Management for Lisfranc Injury with Cuneiform Fracture
Authors: Gu Wenqi , Xu Hongwei , Shi Zhongmin , Zhang Hongtao , Mei Guohua , Xue Jianfeng , Zou Jian , Wang Xiaokang 
Published: October 2019

Category: Midfoot/Forefoot Introduction/Purpose: To summarize and evaluate the treatment and clinical outcome of Lisfranc injury with cuneiform fracture retrospectively. Methods: From January 2014 to December 2017, totally 128 cases of Lisfranc injury with cuneiform fractures were treated in our department including 78 cases of male and 50 cases of female with an average of 42.2 ±10.5 years old . There were 60 left feet and 68 right feet, two of which were suffered from an open injury. From the CT scanning, The avulsion fracture of cuneiform was seen in 48 cases, while other 80 cases were cuneiform body fractures or comminuted fractures. An open reduction and internal fixation were undergone after the improvement of soft tissue condition. Final clinical outcome were evaluated by VAS score and AOFAS midfoot score. Complication were also recorded. Results: 9 cases suffered from an early stage of wound and soft tissue complication, who were cured by a dressing change. All cases were followed for a mean of 16.3 months (range: 6-36 months). The plain radiograph demonstrated that the bone union were achieved on the 12.8±1.3 weeks (range: 11-16 weeks) post-operatively on average. The VAS score at the final follow-up was 1.8±1.7 (range: 0-8), while the AOFAS midfoot score was 81.3±10.4 (range: 35-95). The excellent and good rate was 88.3%. 12 cases of post-traumatic arthritis of midfoot was manifested on the X-ray, five of which underwent a salvage arthrodesis in consequence of the severe symptom and disability. The implant of 49 cases were removed on an average of 13.5 month (9-24 months). Conclusion: The Lisfranc injury is always associated with cuneiform fractures, which should be attached importance to in clinical work. For the simple cuneiform fractures, screw fixation could be performed. The key of management is the restoration of intercunceiform joint. And an anatomical alignment and stable fixation of midfoot may facilitate an acceptable clinical outcome.