bluuebunny/crossref_metadata_2025_split huggingface dataset:
Is Immediate Weight Bearing Safe for Lateral Malleolus Fracture after Surgery?
Authors: Choi Young Rak , Lee Sang-June , Lee Jaehyung , Park Seung-Hwan 
Published: November 2020

Category: Trauma; Ankle Introduction/Purpose: Isolated lateral malleolus fracture is one of the most common fractures. However, there is controversy regarding the rehabilitation protocols used after surgery. In particular, the initiation point for the weight bearing has not been standardized. In the present study, we investigated the prognostic difference between the immediate and delayed weight bearing on isolated lateral malleolus fractures. Methods: Retrospectively, the medical records of matched 50 and 41patients in the immediate and delayed weight-bearing groups were reviewed. All patients were treated with open reduction and internal fixation using an anatomical locking compression plate. In the immediate weight-bearing group (IWB), tolerable weight bearing (i.e., that can be endured immediately after surgery with crutches) was permitted. In the delayed weight-bearing group (DWB), weight bearing was completely restricted for 4 weeks after surgery. Ankle motion exercise were permitted in both groups since postoperative day. Radiographic assessment data and the clinical outcomes were reviewed. Results: There were no significant differences noted in the radiographic assessments and complications between the two groups. Significant differences of shortening the return to work and hospital stays of IWB rehabilitation protocol were confirmed(5.7 vs. 8.0 days, 6.0 vs. 8.0 days in the IBW and DWB groups, respectively). In FAOS, there was a significant difference in the sport factor evaluated at postoperative 3 months(75.5 vs 68.5, respectively). Conclusion: There were no significant differences between the two groups in the postoperative radiological outcome and complications. And benefits of shortening the return to work and hospital stays of IWB rehabilitation protocol were confirmed. Conclusively, immediate weight bearing is recommended in patients with isolated lateral malleolus fracture, following anatomical reduction and firm fixation through surgery.
Patient Outcomes Following Polyvinyl Alcohol Hydrogel Implant of the Lesser Metatarsals
Authors: Chrea Bopha , Day Jonathan , Eble Stephanie K. , Elliott Andrew J. , O’Malley Martin J. , Deland Jonathan T. , Drakos Mark C. 
Published: November 2020

Category: Lesser Toes; Other Introduction/Purpose: Lesser toe metatarsal phalangeal (MTP) joint pathology presents a challenge for surgical treatment. Recently, synthetic cartilage implants have been shown to be safe and efficacious in treating hallux ridigus, offering pain relief while preserving motion at the MTP joint. At our institution, metatarsophalangeal joint arthroplasty using a polyvinyl alcohol (PVA) hydrogel implant has been utilized in the 2nd and 3rd MTP joints for advanced arthritis, failed management of Freiberg’s infraction, and osteochondral defects. We present a case series describing the clinical outcomes of 12 patients following PVA implantation of the 2nd or 3rd MTP. Methods: We retrospectively identified 12 consecutive patients (13 joints) who underwent PVA hydrogel implantation of the 2nd (n=12) or 3rd (n=1) metatarsal head between 2017 and 2019. PVA implant was indicated for advanced arthritis in 6 patients (7 joints), Freiberg’s infraction in 4 patients, and osteochondral defect in 2 patients. Average age was 51 years (range, 20-67), with 100% females. Patient-reported outcomes measurement information system (PROMIS) scores were collected preoperatively and at latest follow-up, with an average follow-up of 20.4 months (range, 8.3 to 29.2). Retrospective chart review was performed to evaluate postoperative complications, including need for revision, implant removal, and persistent pain. Results: Overall, patients demonstrated mean improvement in all PROMIS domains, with a significant improvement in Pain Intensity of 11.9 points (p=0.03) postoperatively. A total of 4 postoperative complications occurred in the 12 patients: one case of AVN at 2 years postoperatively, one revision with removal of the implant and bone grafting of the second metatarsal head at 1 year postoperatively, one periprosthetic fracture at 9 months postoperatively, and one recurrence of pain requiring ultrasound- guided injection at 7 months postoperatively. Three additional patients reported persistent pain postoperatively. Conclusion: This study represents the largest case series to date evaluating the use of PVA hydrogel implant in the surgical correction of lesser toe MTP joint pathology. While the PVA implant presents a viable option in the setting of advanced arthritis, Freiberg’s infraction, and certain osteochondral defects, it is not without complications. The specific indications for use of the PVA implant should be carefully considered before implantation.
Tibial Torsion May Predict Morphology of the Talus
Authors: Ciufo David J. , Baker Erin A. , Fortin Paul T. 
Published: November 2020

Category: Ankle Arthritis; Ankle; Hindfoot Introduction/Purpose: The role of implant positioning in total ankle arthroplasty (TAA) has garnered increasing attention, particularly in defining coronal and sagittal plane alignment. With the ongoing developments in patient specific instrumentation, advanced imaging is becoming a more common tool in preoperative planning. Despite this, there is limited information available on axial rotation of the ankle or variations in anatomy of the talus and foot. We aim to evaluate the rotational profile of the distal tibia and its relationship to morphology of the talus, as well as assess tibiotalar tilt, in a cohort of end-stage arthritic ankles. Methods: Computed tomography (CT) scans and plain radiographs were reviewed in 59 patients with end-stage ankle arthritis. Patients with previous tibial or ankle trauma were excluded. Scans were obtained prior to total ankle arthroplasty surgery as part of standard preoperative planning protocol. Demographic data was recorded. Measurements were obtained at the posterior condyles of the tibial plateau and transmalleolar axis to calculate tibial torsion, as well as along the talar neck and body to evaluate talar angle. Tibiotalar tilt angle was measured on weightbearing mortise view radiographs. Linear regression was performed to evaluate statistical associations between tibial torsion and other measured parameters. Results: The mean tibial torsion was 29.5±9.2 degrees external (range 13.6-50.8 degrees), no internal torsion was found. Mean talar neck-body angle was 38.2±8.8 degrees medial (range 24.1-59.5 degrees). Tibiotalar angle ranged from 26.5 degrees varus to 23.5 degree valgus. There was a statistically significant relationship between increasing tibial torsion and decreasing talar neck-body angle (r=-0.49, p<0.001), demonstrating more angulation of the talar neck corresponding to the least tibial torsion as seen in Figure 1. No relationship was found between tibial rotation and tibiotalar angle when assessing varus/valgus tilt on a spectrum (p=.89) or when evaluating absolute angulation from neutral (p=.43). Our cohort had a mean age of 63.1±8.2 years, and 54% were male. Conclusion: Our cohort displayed wide variation in axial anatomy of the ankle. Our analysis identifies a statistically significant correlation between tibial torsion and morphology of the talus. This is a previously unreported association that could help understand development of foot and ankle deformity and pathology. While there was no clear correlation to degree of tibiotalar angulation, these axial deformities surely play a role in altered foot and ankle mechanics and the development of end-stage ankle arthrosis. In patients undergoing ankle arthroplasty, these are important parameters for the surgeon to consider in conjunction with other aspects of the hindfoot deformity.
Relationship between Demographic and Radiographic Characteristics and 2nd Ray Pathology in Hallux Valgus Patients
Authors: Cronin Samantha , Conti Matthew S. , Williams Nicholas , Ellis Scott J. 
Published: November 2020

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: Hallux valgus can alter load bearing in the foot and may result in secondary pathologies such as hammertoes of the second ray. However, there has been little research on the development of second ray pathology in patients with pre-existing hallux valgus. Additionally, most research examining these three-dimensional foot deformities relies on two- dimensional plain radiographs. The goal of this study was to determine if hallux valgus is associated with second ray hammertoes using three-dimensional weightbearing CT scans. Methods: 71 patients who underwent a modified Lapidus procedure for hallux valgus and had preoperative weightbearing CT scans were separated into 2 outcome groups: (1) hallux valgus only (47 feet), and (2) hallux valgus with second ray hammertoe (29 feet). Preoperative age, BMI, sex, hallux valgus angle (HVA), intermetatarsal angle (IMA), absolute and effective first, second, and third metatarsal lengths, the ratios between metatarsal lengths, Meary’s angle, metatarsus adductus angle (MAA), and pronation were measured. Mean values of continuous variables were compared using one-way ANOVA tests or Kruskal-Wallis tests. Simple logistic regression models were created to evaluate associations between variables and hammertoe occurrence: (1) comparing hammertoe to hallux valgus only, (2) comparing hammertoe to hallux valgus with mild hammertoe removed, and (3) comparing hammertoe to hallux valgus with severe hammertoe removed. Multivariable logistic regression models were generated to evaluate potential risk factors for hammertoe after adjusting for patient age and BMI. Results: Patients in the hammertoe group were found to be significantly older and have significantly higher BMIs, HVAs, effective second MT lengths, IMAs, and more apex plantar Meary’s angles (all P-values < 0.05). BMI and HVA were also found to be significant predictors of second ray hammertoe in simple logistic regression models (OR=5.66 (95% CI: 1.67-22.79) and OR=4.5 (95% CI: 1.13-21.06), respectively). The multivariable analysis demonstrated that higher IMA and a more apex plantar Meary’s angle were the only significant predictors of second ray hammertoe risk (P= 0.03 and P = 0.01, respectively) once corrected for age and BMI. Conclusion: Significant associations were found between older age, higher BMI, and more severe deformity and the occurrence of hammertoe in hallux valgus patients. These relationships may aid in determining which patients are at a greater risk of progressing to secondary pathologies and which patients could potentially benefit from earlier surgical intervention to correct hallux valgus.
Contribution of First Tarsometatarsal Joint Fusion to Deformity Correction in the Treatment of Adult Acquired Flatfoot Deformity
Authors: Day Jonathan , Conti Matthew S. , Williams Nicholas , Ellis Scott J. , Deland Jonathan T. , Cody Elizabeth 
Published: November 2020

Category: Midfoot/Forefoot; Other Introduction/Purpose: Severe adult-acquired flatfoot deformity (AAFD) is often associated with painful medial column collapse at the naviculocuneiform (NC) joint. The purpose of this study was to examine the role of first tarsometatarsal (1st TMT) fusion combined with subtalar fusion in correcting deformity at this joint. Methods: We retrospectively analyzed 40 patients (41 feet) who underwent 1st TMT and subtalar (ST) fusion as part of a flatfoot reconstructive procedure. We assessed six radiographic parameters both preoperatively and at a minimum of 6 months postoperatively, including talonavicular (TN) coverage angle, lateral talo-first metatarsal angle, lateral talocalcaneal angle, calcaneal pitch, hindfoot moment arm, and a newly defined navicular-cuneiform incongruency angle (NCIA). Patient-Reported Outcomes Measurement Information System (PROMIS) clinical outcomes were assessed preoperatively and at a minimum 1 year follow-up. Results: The NCIA demonstrated excellent interobserver reliability, with no significant change between pre- and postoperative measurements. All other radiographic parameters, except calcaneal pitch, demonstrated statistically significant improvement postoperatively (p <0.01). Overall, patients had statistically significant improvement in all PROMIS domains (p <0.01), except for depression. Worsening NC deformity was not associated with worse patient-reported outcomes. Conclusion: Our data suggests that when addressing collapse of the medial arch in patients with AAFD, fusion of the 1st TMT joint in combination with other procedures leads to acceptable radiographic and clinical outcomes. There was no change in deformity at the NC joint at short-term follow-up, and patients achieved significant improvement in multiple PROMIS domains. Based on our findings, deformity through the NC joint does not significantly impact clinical outcomes. In addition, the NCIA was established as a reliable radiographic parameter that can be used to assess NC deformity in the presence of talonavicular and/or 1st TMT fusion. [Table: see text]
Perspectives From the Foot and Ankle Department at an Academic Orthopedic Hospital During the Surge Phase of the COVID-19 Pandemic in New York City
Authors: Day Jonathan , MacMahon Aoife , Roberts Matthew M. , Drakos Mark C. , Johnson A. Holly , Levine David S. , O’Malley Martin J. , Cody Elizabeth , Behrens Steve B. , Deland Jonathan T. , Demetracopoulos Constantine A. , Elliott Andrew J. , Ellis Scott J. 
Published: November 2020

Category: Other Introduction/Purpose: Cases of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus (COVID-19) first emerged in Wuhan, China, in December 2019. Since then, the virus has spread globally at a rapid pace. The first case in New York City was reported on March 1, 2020, and the World Health Organization (WHO) declared a pandemic on March 11, 2020. New York City rapidly became the epicenter of the pandemic, with hospitals across the city making a number of changes to accommodate the influx of COVID-19 patients. Here, we describe our experience in adapting to the COVID-19 pandemic as a department consisting of 10 foot and ankle fellowship-trained surgeons with up to 28 years of individual experience in an academic orthopedic hospital. Methods: Information was obtained from direct interviews with surgeons in the Foot and Ankle Service and from our institution’s intranet. Additional information was obtained by viewing twice-weekly livestreams from March 27th, 2020 to May 1st, 2020 held by the Surgeon-In-Chief, which detailed hospital-wide policies and initiatives being implemented in the wake of the COVID-19 pandemic. Results: On March 17, 2020, all elective surgeries were suspended at our institution, and a list of essential procedures was established. In-person clinical visits were limited to new patients being evaluated for essential procedures and first postoperative visits for returning patients, with all patients receiving pre-visit and on-site screening for COVID-19. All other new patient and follow-up appointments were conducted via telehealth visits. Much of our main hospital was repurposed to accept transfers of both COVID-negative and COVID-positive patients. A postanesthesia care unit and a floor of 9 operating rooms were repurposed as negative-pressure rooms for the care of critical COVID-positive patients on ventilators. An Orthopedic Triage Center (OTC) was established to relieve the patient load in the emergency departments of other hospitals in the city. Conclusion: By changing the way we delivered foot and ankle care and repurposing the roles of our employees and our institution, we have adapted strategies to continue delivering care to our patients. As we transition toward a ‘new normal,’ our goals are to gradually progress toward normal operations while keeping our patients and employees safe. With these gradual steps, we hope to emerge from this pandemic stronger and ready to adapt to the ever-changing needs of our community.
True Antiglide Fixation of Weber B Ankle Fractures has Lower Rates of Removal of Hardware
Authors: DeKeyser Graham J. , Kellam Patrick , Higgins Thomas F. , Rothberg David , Haller Justin , Marchand Lucas S. 
Published: November 2020

Category: Trauma; Ankle Introduction/Purpose: Plating of unstable OTA/AO 44-B1 lateral malleolus fractures has been associated with pain, peroneal irritation, and subsequent hardware removal. There has been speculation that this is due to the prominent plate and distal screw placement. Previous studies have looked at posterior vs lateral plate position but have had fairly low numbers in each group. The purpose of this study was to retrospectively compare the rates of hardware removal in unstable OTA/AO-type 44-B1 lateral malleolus fractures fixed with a posterior, true anti-glide plate with no screws in the distal segment versus those that were fixed with a similarly placed posterior, neutralization construct that included screws in the distal fragment thus evaluating the role of the distal screw in rates of hardware removal. Methods: Skeletally mature patients that were treated for an isolated OTA/AO 44-B1 fracture over a ten-year period (2007- 2017) were reviewed. Fractures treated with a single posterior plate were included and those fixed with a direct lateral plate were excluded. We evaluated post-op radiographs to determine application of a true anti-glide plate or a neutralization plate with screws in the distal fragment. Radiographic follow-up was used to determine bony union, malunion and need for hardware removal. Hardware removal was determined as entire plate removal; isolated syndesmotic screw removal was not included. Patients were excluded if they had less than six months of follow up. Relative risk was determined for the rate of hardware removal based on fixation technique. Results: There were 548 OTA/AO 44-B1 fractures treated over the course of ten years (2007-2017). After screening, 88 patients were included in the study. The majority of excluded patients lacked adequate follow-up. Average age of the cohort was 46 years old (range 17-84), with 47 females and 41 males included. Average length of follow up was forty months (range 6.1- 140.3). There were 28 patients in the true anti-glide plate group and sixty in the neutralization plate group. Five (18%) in the anti- glide plate group and 19 (32%) in the neutralization plate underwent a second procedure of hardware removal. Relative risk of hardware removal was 0.56 (95% CI 0.23-1.36, p=0.2). There was a 100% union rate with 0% malunion in both groups. Conclusion: Anti-glide plating has a near 50% relative risk reduction in the rate of hardware removal when compared to posterior based neutralization plating. Fractures fixed with or without distal screws had equivalent excellent results related to bony union and alignment. A true anti-glide plating construct should be considered as a safe and effective way of managing OTA/AO 44-B1 lateral malleolus fractures with a lower relative risk of a second operation for hardware removal.
Radiographic Outcomes of Intramedullary Fixation of the Distal Fibula in Unstable Ankle Fractures
Authors: Delman Connor , Saiz Augustine , Haffner Max , Arora Aman , Bhatti Satninderdeep , Giza Eric , Kreulen Christopher D. 
Published: November 2020

Category: Trauma; Ankle Introduction/Purpose: Intramedullary fixation of the distal fibula in unstable ankle fractures provides an alternative treatment strategy to traditional techniques and may reduce the complication profile. While often reserved for soft-tissue protection or elderly patients, the indications for this technique continue to expand. The purpose of this study was to evaluate the radiographic outcomes of ankle fractures treated with intramedullary fixation of the distal fibula with screw or flexible fixation of the syndesmosis. Methods: A retrospective case-series was performed of patients >18 years old with unstable ankle fractures treated at a single institution. Patients were treated with intramedullary fixation of the distal fibula and screw or suture-button fixation of the syndesmosis if indicated. Radiographic parameters measured included the medial clear space, tibiofibular overlap, tibiofibular clear space, talocrural angle, and fracture displacement. Fracture pattern, comorbidities, and postoperative complications were also assessed. Results: Fourteen patients (6 males, 8 females) with torsional ankle fractures (71% SER-IV patterns) were included in the study with a mean follow-up period of 5 months. Five patients had suture-button fixation and one patient had trans-syndesmotic screw fixation of the syndesmosis. All patients had improvement in radiographic parameters following surgical stabilization. Medial clear space decreased from a mean of 5.6 +- 3.1mm to 2.8 +- 0.79mm (p<0.0001). Tibiofibular overlap increased from 0.4 +- 2.7mm to 3.0 +- 1.5mm (p<0.05). Fracture displacement of the fibula decreased from 3.5 +- 1.8mm to 0.61 +- 1mm (p<0.0001). There was no statistically significant difference between preoperative and postoperative tibiofibular clear space and talocrural angle measurements. There were no lateral wound complications, revision surgeries, or hardware complications. Conclusion: This case-series demonstrates the successful use of intramedullary fixation of distal fibula fractures in unstable ankle injuries with good radiographic and clinical outcomes. The use of an intramedullary device does not preclude trans-syndesmotic screw or suture-button fixation of concomitant syndesmotic injuries. Orthopedic surgeons can consider this treatment strategy as an alternative to traditional techniques.