bluuebunny/crossref_metadata_2025_split huggingface dataset:
Tuber-to-Anterior Process Angle (TAPA): A Cadaveric Study and Surgical Technique for Placing Axial Calcaneal Screws
Authors: Stupay Kristen L. , Briceno Jorge , Velasco Brian , Kwon John Y. 
Published: October 2019

Category: Ankle, Hindfoot Introduction/Purpose: Operative management of displaced intra-articular calcaneus fractures frequently involves placement of P: A screws in order to maintain calcaneal length and axial alignment. While plate fixation may still be more commonly utilized, screw-only fixation for the treatment of these fractures has been demonstrated by several authors to be safe and effective. Directing fixation from the tuber into the anterior process can be challenging. Understanding the calcaneal long-axis as it relates to the long-axis of the foot, a measurement we call the Tuber-to-Anterior Process Angle (TAPA), can facilitate the ease and accuracy of guide-wire and cannulated screw placement. The goals of this study are to define the TAPA, and to report a surgical technique which uses this angle to facilitate axial screw placement. Methods: Eight cadaver feet were utilized. A longitudinal pin was placed from the center of the posterior calcaneal tuber to the 2nd metatarsal heads. Next, the calcaneocuboid joint was exposed, and a wedge of cuboid was removed. A calcaneal pin was then placed, exiting at the center of the anterior process. The tips of two small K-wires were impacted into the medial and lateral-most aspects of the articular surface. A true axial view of each specimen was obtained. On these images, a digital line was drawn from the posterior tuber starting point and the central calcaneal pin, representing the calcaneal long-axis. The angle subtended by this line and the long-axis of the foot represents the TAPA. Digital lines were drawn between the posterior tuber starting point and the medial and lateral K-wires, and the range between their subtending angles represents the axial plane tolerance for screw placement within the anterior process. Results: The average TAPA measured 10.9 ± 1.3 degrees (range: 8.4-13.0). The average angle, as measured to the medial extent of the anterior calcaneus, measured 2.8 ± 1.3 degrees (range: 0.4-4.3). The average angle, as measured to the lateral extent of the anterior calcaneus, measured 19.0 ± 2.7 degrees (range: 15.7-22.7). Conclusion: Knowledge of the Tuber-to-Anterior Process Angle (TAPA), found to be 10.9 degrees (± 1.8 degrees) laterally deviated from the long-axis of the foot, simplifies placement of posterior-to-anterior screws in the calcaneus. Understanding this relationship reduces reliance on intraoperative axial fluoroscopy and increases operative efficiency. Furthermore, this knowledge can be applied during other procedures in which axial screw placement is performed, such as with corrective calcaneal osteotomy.
The Use of Structurally Augmented 3D Printed Cages in Segmental Defects of the Tibial Shaft
Authors: Tracey Joseph , Parekh Selene 
Published: October 2019

Category: Trauma, Emerging Technology Introduction/Purpose: Modern day management of segmental defects of the tibia shaft (SDTS) involve autologous nonvascularized grafts, autologous vascularized contralateral fibula grafts, as well as bone transport distraction osteogenesis, however single stage titanium cages with adjuvant biologics continue to demonstrate advantages. With the development of advanced additive manufacturing further modalities such as complex variable lattice structure and submicron texture may be incorporated into custom fit implants. We aim to further investigate the potential of this technology on osteoinduction, and hypothesize early bone in-growth. Methods: A retrospective analysis was performed on 3 patients undergoing custom cage implantation for SDTS. All three patients were male with an average age of 60, 2 patients were diabetic, and one was a smoker. All three cases were performed in the setting of post-infection salvage. Pertinent demographic and clinical history was retrieved through the medical record. Results: All three cases were uncomplicated in the post-surgical period, and early bone in-growth was demonstrated in successive follow-ups. One case was single-staged and built into a prior total ankle arthroplasty, the next was a deformity correcting intramedullary rod that became infected requiring two-stage salvage with an antibiotic spacer and subsequent custom cage with Intramedullary rod supplementation, and the third case was a two-stage trauma salvage initially using an antibiotic spacer with subsequent custom cage implantation. Conclusion: 3D printed custom cages were found to be a safe and efficacious option for management of SDTS, with demonstrated early bone in-growth. Considering the incorporation of advanced additive manufacturing techniques, strong implementations may be present for salvage cases.
Online Ratings and Reviews of American Orthopedic Foot and Ankle Surgeons
Authors: Velasco Brian T. , Chien Bonnie , Kwon John Y. , Miller Christopher P. 
Published: October 2019

Category: Practice Management Introduction/Purpose: Utilization by patients of physician rating websites continues to expand. There is limited information on how these websites function and influence patient perception and physicians’ practices. No study has specifically investigated online ratings and comments of orthopedic foot and ankle surgeons. In this study, we identified what factors impact online ratings and comments for this subset of surgeons. Methods: A total of 210 orthopedic foot and ankle surgeons in or near metropolitan areas were randomly selected from the American Orthopaedic of Foot & Ankle Society (AOFAS) website. Demographic information, ratings (number of stars), and comments were reviewed on the three most visited public domain physician ratings websites: HealthGrades.com (HealthGrades), Vitals.com (Vitals), and Ratemds.com (Ratemds). Content differences between positive and negative comments were evaluated. Results: Orthopedic foot and ankle surgeons had a mean rating of 4.03 ± 0.57 out of 5 stars. A high percentage (84%) of the total number of ratings were either 1-star (17%) or 5-stars (67%). Most positive comments related to outcome, physician personality, and communication while most negative comments related to outcome, bedside manner, and waiting time. Chi-square analysis revealed statistically significant proportions of positive comments pertaining to surgeon-dependent factors (eg, physician personality, knowledge, skills) and of negative comments concerning surgeon-independent factors (eg, waiting time, logistics). Conclusion: This is the first study examining online ratings and written comments of orthopedic foot and ankle surgeons. Surgeons had a generally favorable rating and were likely to have positive comments. Patients were likely to write positive comments about surgeon personality and communication, and negative comments pertaining to bedside manner and waiting time. Knowledge and management of online content may allow surgeons to improve patient satisfaction and online ratings.
The Captain’s View: A Novel Radiographic View to Assess Axial Alignment of the Calcaneus
Authors: Velasco Brian , Moura Bruno , Kwon John 
Published: October 2019

Category: Hindfoot, Trauma Introduction/Purpose: The axial alignment of the calcaneus has paramount importance in the management of these fractures. The Harris view has long stood as the recommended radiograph to assess axial alignment. However, given the obliquity at which the radiograph is obtained, it doesn´t represent a true axial view and is subject to inaccuracies secondary to rotational malpositioning of the foot and mismeasurement of angulation. Multiple reports have described the axial alignment as a surgical outcome, but usually this assessment of the residual deformity have no described method. The objectives of this study are to evaluate the capacity of Harris view to assess axial alignment in a cadaveric model and to describe the use of a true AP view of the calcaneus that we have named Captain´s view. Methods: Five below knee amputated fresh-frozen cadaveric specimens were used in the study. For each specimen, the soft tissues over the lateral side were removed to access to the lateral wall. A small wedge of the cuboid was removed to visualize the center of the calcaneocuboid articular surface. LCA-guide and a cannulated drill were used to create a tunnel in the axis of the calcaneus. An oblique osteotomy was performed in order to simulate a non-comminuted fracture. Varus deformity was created by inserting solid radiolucent wedges into the osteotomy to create models of 10, 20, and 30 degrees of varus angulation. Harris and Captain views were obtained for each specimen with 0 (control), 10, 20, and 30 degrees of varus malalignment. Measurements of the deformity were made digitally on each fluoroscopic image. Results: The average degrees of varus in Harris views were 10,9 (5,5-16); 11,5 (8,2-13,6); and 18,3 (13,3-23,6) for 10,20 and 30 degrees of deformity respectively. The average degrees of varus in Captain´s view were 13,0 (7,3-20,9); 18,4 (11,7-23,5); and 28,2 (24,4-31,1) for 10,20 and 30 degrees of deformity respectively. The average degrees of error for varus deformity in Harris views were 4,1 (41%); 8,4 (42%) and 11,6 (39%) for 10,20 and 30 degrees of deformity respectively. The average degrees of error for varus deformity in Captain´s views were 4,8 (48%); 3,6 (18%) and 2,8 (8%) for 10,20 and 30 degrees of deformity respectively. Conclusion: The results of this study show a high rate of mismeasurement for both radiographic views. Despite the average angles have a clear correlation with the severity of varus, the wide range of error observed between specimens make this assessment unreliable and inaccurate. We observed an improvement of accuracy of captain´s view for more severe deformities, but not with Harris views which maintain a 40% mismeasurement in all the settings. Therefore, intraoperative Harris views should not be used in isolation to evaluate axial alignment and Captain´s view provides an additional perspective that can be useful to rule out severe deformities.
Biomechanical Evaluation of a Novel Lisfranc Injury Cadaveric Model Using Supination and Pronation Testing
Authors: Wagner Emilio , Wagner Pablo , Baumfeld Daniel , Baumfeld Tiago , Prado Marcelo , Nery Caio 
Published: October 2019

Category: Basic Sciences/Biologics, Sports, Trauma Introduction/Purpose: Lisfranc joint injuries occur due to direct or indirect trauma, where twisting forces are applied. Cadaveric models have been used to evaluate injury patterns and fixation methods, but a frequent limitation has been historically the small amount of joint displacement after injury, which hinders a correct evaluation of the damage degree and reconstruction effectiveness. Our hypothesis was that adding pronation and supination motion to a cadaveric model would produce reliable and measurable joint displacements. Methods: 24 fresh frozen lower leg cadaveric specimens were utilized. The medial (C1), intermediate (C2) cuneiforms, first (M1) and second (M2) metatarsal bones were marked. A complete ligament injury was performed between C1-C2 and C1-M2 in 12 specimens (Group 1), and between C1-C2, C1-M2, C1-M1 and C2-M2 in 12 matched specimens (Group 2). Supination and pronation motion of the forefoot relative to the hindfoot was obtained through internal and external rotation of the tíbia, using an Instrom machine. A 3D Digitizer was used to measure distances between the bones already mentioned. Results: Distance C1-C2 increased 3 mm after ligament injury with supination motion (p<0.05). Distance C1-M2 increased 4 mm after ligament injury with pronation motion (p<0.05). Distances between C1-M1 and C2-M2 only changed in Group 2, increasing 3 mm and 2 mm respectively (p<0.05). Conclusion: Pronation and supination motion of the forefoot relative to the hindfoot produces measurable joint displacements in a cadaveric Lisfranc injury model. We believe this new method for testing cadaveric lisfranc injuries will allow a better understanding of injury patterns and repair or reconstruction techniques.
Radiographic Analysis of Pronation in Operated Hallux Valgus: Short Term Follow-Up
Authors: Wagner Emilio , Wagner Pablo , Keller Andres , Bernal Nazira , Lopez Mario , Caicedo Nathaly , Etchevers Gaston , Mococain Pablo , Zanolli Diego 
Published: October 2019

Category: Bunion Introduction/Purpose: Hallux Valgus (HV) is a multiplanar deformity with metatarsal varus and pronation. Pronation is a frequently undiagnosed and/or untreated deformity parameter being a recognized postoperative relapse factor. The objective of this research is to estimate the pronation prevalence in HV and evaluate the pronation correction after conventional Hallux Valgus surgery. Methods: 105 patients with operated Hallux Valgus were followed between 2010 and 2016. Mean age and follow up (months) was 53 and 23 respectively. For all patients, pre and postoperative angular measurements (Pronation angle, hallux valgus angle, HVA, and intermetatarsal angle, IMA) and the operative technique used was recorded. For pronation measurements, a 4-stage classification was used by means of 4 metatarsal templates with different degrees of pronation (0, 10, 20, 30 degrees). Surgical techniques used were Chevron, Scarf and Poscow. Results: Regarding pronation angle, 95 out of 105 patients (90%) had some degree of metatarsal pronation (10% had no pronation). The most common pronation value was 20 degrees (60%). No change in metatarsal pronation angle was observed at final follow up with any technique used. Regarding HVA and IMA pre/postoperatively: HVA: 29/11, IMA: 14/8. Chevron, Scarf and Poscow were used in 15, 67 and 23 patients respectively. 66% of cases decreased sesamoid position in one or more stages. Conclusion: Metatarsal pronation is a frequent finding in Hallux Valgus patients (90%). The most common pronation deformity is 20 degrees. It was not corrected with any technique used (Chevron, Scarf, Poscow). This fact is explained probably because these osteotomies are purely translational aiming to correct the metatarsal varus and not the metatarsal pronation.
Predictors of Wait Time in the Orthopaedic Foot and Ankle Clinic
Authors: Wakefield Connor J. , Wu Kevin , Skipor Joe , Ravanam Angad , Benko Savannah , Bohl Daniel D. , Lee Simon , Hamid Kamran S. 
Published: October 2019

Category: Health Sciences Research Introduction/Purpose: Wait times represent a critical component of the patient experience, and prolonged waits are correlated with decreased patient satisfaction. We hypothesized that time spent waiting for radiology is the largest contributor to total patient wait time in our orthopedic foot and ankle clinic. Methods: A prospective, observational study was conducted in the outpatient orthopaedic foot and ankle clinic at a tertiary medical center. A total of 210 new and follow-up adult patients were enrolled. Patients were tracked from arrival until checkout with multiple time points being recorded by a trained observer. The time between patient arrival and first contact with the orthopaedic surgeon was broken down into five distinct categories. Total time between patient arrival and first contact with the orthopaedic surgeon was tested for association with patient and appointment characteristics using Student’s t-test. Results: The average total time spent waiting for first contact with the orthopaedic surgeon was 57.1±30.4 minutes. The largest contributor was time spent waiting for an exam room (33.1±25.5 minutes), followed by time spent waiting for radiologic imaging (21.7±19.9 minutes), time spent waiting for resident/PA (12.2±10.9 minutes), and time spent waiting for attending surgeon after seeing resident/PA (11.7±9.3 minutes). Factors contributing to a longer overall wait included obtaining x-rays at the visit (+15.4±4.2 minutes, 95% confidence interval [CI]=+7.0 to +23.8, p<0.001) and failure to complete patient paperwork beforehand (+36.9±5.3 minutes, CI=+26.4 to +47.4, p<0.001; Table 1). In contrast, overall wait time was not associated with age≥50 years, female sex, late arrival, or outside medical records needing review. Conclusion: Time spent waiting for assignment to an exam room was the largest contributor to the time between patient arrival and first contact with the attending surgeon. In order, the other contributors were time spent waiting for radiology, time spent waiting for the resident/PA, and time spent waiting for the attending surgeon after seeing the resident/PA. Obtaining x-rays increased patient wait time and completing patient paperwork beforehand decreased patient wait time. Orthopaedic foot and ankle surgeons should work to avoid unnecessary x-rays and encourage completion of patient paperwork before arrival in order to optimize clinic flow and decrease patient wait times.
Deformity and Clinical Outcomes Following Surgical Correction of Charcot Ankle
Authors: Wallace Stephen , Liskutin Tomas E. , Schiff Adam P. , Pinzur Michael S. 
Published: October 2019

Category: Ankle, Ankle Arthritis, Diabetes, Hindfoot, Trauma Introduction/Purpose: Deformity associated with Charcot Foot Arthropathy leads to a poor quality of life in affected individuals. Deformity in the midfoot appears to be predictive of clinical outcomes following surgical correction. The goal of this retrospective study was to determine if that same methodology could be applied to patients treated for Charcot Foot Arthropathy involving the ankle joint. Methods: Fifty-six consecutive patients underwent surgical reconstruction of Charcot Foot deformity involving the ankle joint by a single surgeon over a fourteen year period. Preoperative patient characteristics and tibiotalar alignment, were recorded. Surgical treatment included single stage debridement of active infection and ankle arthrodesis with application of a circular external fixator when infection was present (39 of 56, 69.6%) or retrograde locked intramedullary nailing in the absence of infection (17 of 56, 30.3%). Clinical outcomes were graded based on limb salvage, resolution of infection and chronic wounds, and the ability to ambulate with therapeutic footwear or accommodative orthoses. The average follow-up was 7.5 (range 1.1-14.0) years. Results: One patient died at 134.3 weeks following surgery of unrelated causes and 8 underwent amputation. Twenty eight of 56 patients (50.0%) achieved a favorable (excellent or good) clinical outcome. There was no significant association between preoperative or postoperative alignment and clinical outcomes. Insulin-dependent diabetics were approximately 3 times more likely to have a poor clinical outcome. Conclusion: Surgical correction of Charcot deformity involving the ankle joint was associated with a high complication rate and risk for failure. The lessons learned from this highly co-morbid patient population with complex deformities can be used as a benchmark for applying modern surgical techniques.
Outcomes of Endoscopic Treatment for Plantar Fasciitis: A Systematic Review
Authors: Ward Leona , Shimozono Yoshiharu , Kennedy John G 
Published: October 2019

Category: Arthroscopy, Hindfoot Introduction/Purpose: Open plantar fascia release is an established surgical treatment for plantar fasciitis traditionally. However, it has long recovery period and complications with conflicting late results. Recently, endoscopic plantar fascia release has gained popularity, providing good outcomes with early return to activity. However, there is still a paucity of overall clinical data regarding outcomes and complication rates following endoscopic procedure for the treatment of plantar fasciitis. The purpose of the current study was to systematically review the outcomes of endoscopic plantar fascia release in the treatment of plantar fasciitis. Methods: A systematic review was preformed using, MEDLINE, EMBASE and Cochrane library databases based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies included were evaluated with regards to level of evidence (LOE) and quality of evidence (QOE) using the Coleman methodological score. Clinical outcomes and complications were also evaluated. Results: Twenty-one studies including 601 feet were included in this systematic review. The mean patient age was 48.5±5.2 years, and the mean follow-up time was 26.9±22.7 months. Sixteen studies used the AOFAS score for clinical outcome measure. The mean preoperative AOFAS score was 52.3±24.1 and the postoperative score was 88.8±4.1. The VAS score was utilized in 10 studies. The mean preoperative score was 7.8±0.8 and the postoperative score was 1.8±0.7. In total 111 of 601 (18.7%) patients had complications. The most common complication was recurrence of pain with 45 patients (7.5%). Twenty-two patients (3.7%) experienced paraesthesia and numbnesss. Seventeen patients (2.8%) required subsequent operations including gastrocnemius release, hematoma drainage, and baxter nerve release. Conclusion: The current systematic review demonstrates that overall there were good clinical and functional outcomes following endoscopic procedure for the treatment of plantar fasciitis. However, there was a relatively high complication rate (18.7%) associated with the endoscopic procedures. Due to the low level of evidence and poor qualities of evidence, further well designed studies are necessary to determine the clinical outcomes and complications of endoscopic plantar fasciotomy.
Local Delivery of Antibiotics in the Context of Chronic Diabetic Foot Infection with Bony Involvement: A Case Series of 102 Patients
Authors: Widnall James , Harvey David , Evans Paul , Jackson Gillian , Platt Simon 
Published: October 2019

Category: Diabetes Introduction/Purpose: Diabetic foot infection (DFI) is a devastating condition which poses risk to both life and limb. Treatment principles revolve around surgical debridement, dead space management, delivery of both local and systemic antibiotics and soft tissue cover. Dead space management and local antibiotic delivery can be achieved simultaneously by using an antibiotic loaded bone substitute. We report our retrospective case series of patients treated with surgical management involving local antibiotic delivery via calcium sulphate bone substitute (Stimulan™; Biocomposites, Keele, UK). Methods: All patients between January 2015 and June 2018 with DFI and proven bony involvement presenting to our university teaching hospital were treated via our extensive MDT approach. A total of 102 patients were included. Surgical debridement was performed along with simultaneous insertion of 10 ml calcium sulphate with 1 g vancomycin and 240 mg gentamycin. Outcome was classified as resolved, requiring prolonged treatment from other medical (endocrinologist) or surgical (plastic surgery, limb reconstruction) services or salvage surgery in the form of proximal amputation. Results: 45.1% of patients had a partial amputation at the index surgery. 52% had bony debridement and just 2.9% had soft tissue debridement in conjunction with calcium sulphate insertion. The surgical wound was primarily closed in 56.8% of patients. 7 patients had delayed wound closure and 36.2% of patients healed via secondary intention. 74 patients (72.5%) had resolution of their DFI with bony involvement following surgical intervention. 21 (20.6%) patients needed further treatment from allied specialties. 7 (6.9%) patients required salvage surgery in the form of a below knee amputation. There was no correlation between either closure type (2 p-value 0.75) or index surgery type and outcome (2 p-value 0.64). Conclusion: DFI is a difficult clinical scenario to treat effectively. An MDT approach is undoubtedly key to a good outcome. We believe that the use of calcium sulphate can be a useful adjunct at the time of surgical debridement to aid in both dead space management and allow local antibiotic delivery.