bluuebunny/crossref_metadata_2025_split huggingface dataset:
Treatment of Insertional Achilles Tendinopathy with MRI Confirmed Small or No Tear Using a Gastrocnemius Recession
Authors: Long Joseph M , Whitehead Brent , Zehnder David , Large Bryan , Cheney Nicholas , Law Timothy 
Published: October 2019

Category: Ankle Introduction/Purpose: Insertional Achilles tendinopathy can be a distressing problem for an active patient. Treatment begins conservatively, and when this fails a patient’s next best option may involve operating on the affected tendon. Depending on the disease state of the tendon, the surgeon may decide to repair or augment the Achilles with a flexor hallucis longus (FHL) transfer. The current literature supports the gastrocnemius recession for non-insertional cases, but is inconsistent in its efficacy for insertional cases. Our study looks at how patients with insertional Achilles tendinopathy with a small tear involving 20% of the tendon or less responded to an isolated gastrocnemius recession. Our hypothesis was that patients could do well without the need for a large repair or FHL transfer procedure. Methods: We retrospectively reviewed patients who underwent an isolated gastrocnemius recession for recalcitrant insertional Achilles tendinopathy between January 2015 and July 2018. Patients were included based on the diagnosis of insertional Achilles tendinopathy, having an MRI confirming tendinopathy, a tear involving less than 20% of the tendon or no tear, and no other concurrent pathologies. These criteria yielded 14 patients. One of these 14 patients was removed from the data analysis due to non-surgical complaints after surgery stemming from new onset posterior ankle pain. The patient charts were reviewed for their subjective VAS pain scores during office visits pre and postoperatively. Immediate preoperative visit, initial postoperative visit and final visit VAS scores were recorded. Results: The average time of chart follow up for the 13 patients included in the study was 15.5±10.5 weeks postoperatively (range 4-38). 2 patients were found to have a tear <20% (15%), and the remaining 11 patients were found to have no tear on their MRI (85%). The average final preoperative VAS pain score for the patients was 5.4±1.8 (range 3-9). The average final postoperative VAS pain score for the patients was 0.9±1.3 (range 0-5). These values were found to be statistically different (p<0.001). Of note all patients saw a reduction in their pain score of at least 2 points. Conclusion: Previous literature is inconclusive on the efficacy of the gastrocnemius recession for insertional Achilles tendinopathy. No other study has identified the amount or type of tendon involvement by advanced imaging. Our study supports the notion that patients with MRI confirmed tendinopathy and a tear involving less than 20% of the tendon or no tear, often do quite well in reaching a reduction in their pain. Our study is limited in power due to our small sample size, but the results suggest that this procedure deserves more attention for the treatment of insertional Achilles tendinopathy when appropriate.
Subtalar Nonunion Following Tibiotalocalcaneal Fusion Using an Intramedullary Nail: A Case Series of Errant Entry Points
Authors: Martella Anthony , Yue Ruixian , Boin Michael , Rogozinski Jonathan , Flanigan Trenden , Purcell Kevin , Laughlin Richard 
Published: October 2019

Category: Hindfoot Introduction/Purpose: Tibiotalocalcaneal (TTC) arthrodesis is a procedure used to treat hindfoot deformity and/or arthritis. Retrograde intramedullary nails have been used as a method of fixation. The nails are either straight or have a bend to accommodate valgus alignment of the hindfoot. Studies comparing nail types or analysis of nonunions are lacking in the available literature on the subject despite a reported nonunion rate of up to 20%. The purpose of this study was to report a series of subtalar nonunions that all had an entry point that was too medial on the calcaneus resulting in inadequate purchase of the nail in the calcaneus. Methods: Six cases of subtalar nonunion were retrospectively reviewed. All were referred for second opinion. Evaluation consisted of examination, radiographs and CT scans. Patient demographics, comorbidities and findings common to all cases were recorded. Results: Presenting complaints in all cases were persistent swelling. Non-neuropathic cases all had hindfoot pain. In this series, all the implants were straight nails. Radiographs and CT scans revealed that all cases were done for severe valgus deformity with subtalar subluxation. In each of the cases, the deformity was under corrected and the nail entry point was too medial on the calcaneus which resulted in reaming out the medial wall of the calcaneus, decreasing the amount of fixation obtained with the nail. In each of the cases, the medial wall of the calcaneus was deficient and the nail had no medial containment. Conclusion: Severe valgus deformity with subtalar subluxation is a risk factor for subtalar nonunion when the deformity is under corrected and a straight nail is used. Ensuring that the tibia talus and calcaneus are collinear and that the entry point in the calcaneus is sufficiently lateral are important factors to consider when addressing this type of deformity. Accurate intraoperative imaging is essential to ensure proper positioning of the entry point to avoid reaming out the medial wall of the calcaneus and to ensure adequate purchase of the nail in the calcaneus.
Does Insurance Status Affect Access to Care Among Ankle Fracture Patients? An Institutional Retrospective Study
Authors: McKissack Haley , He Jun Kit , Moraes Leonardo V. M. , Anderson Matthew , Wislon John T. , Viner Gean C. , Jha Aaradhana J. , Mcmurtrie James T. , Shah Ashish B. , Naranje Sameer M. 
Published: October 2019

Category: Ankle, Trauma Introduction/Purpose: Ankle fractures are urgent, and often emergent injuries which require immediate evaluation and treatment. Delayed access to care may subject the patient to increased risk of complications, particularly if surgical management is warranted. Medicaid is a state and federal insurance program in place for those with low income, which has previously been associated with delayed access to care among patients with ACL tears and total hip arthroplasties. Studies have also shown delayed access to care among ankle fracture patients; however these studies have used hypothetical patients rather than existing data regarding timeliness of care. The purpose of this study is to assess whether patient insurance status affects access to care using data from a single institution. Methods: Patients who underwent open reduction and internal fixation for an ankle fracture between the years 2008 and 2018 at a single institution were identified by CPT codes 27829, 27784, 27822, 27814, 27769, 27792, and 27766. Patients who had polytraumatic injuries, open injuries, Medicare, no insurance, indigent/charity insurance, self-pay, or whose insurance information was not available were excluded. Insurance status was retrospectively identified as well as date of injury, date of first visit to the institution’s hospital for the injury, and date of surgery. Time elapsed from date of injury to date of surgery, date of injury to date of first visit, and date of first visit to date of surgery was compared between patients with private insurance and Medicare. P-values of less than 0.05 were considered statistically significant. Results: Results showed statistically significant differences in mean time from injury to first appointment and mean time from injury to surgery between patients enrolled in Medicaid and those with private insurance. Average time from injury to first appointment was 3.1 days and 6.6 days for privately-insured patients and Medicaid patients, respectively (p<0.0001). Average time from injury to surgery was 8.1 days for patients with private insurance, and 12.7 days for patients enrolled in Medicaid (p<0.0001). Conclusion: Patients who are enrolled in Medicaid have significantly delayed access to care as compared to those who have private insurance. For ankle fracture patients this is a critical healing time, and delayed care may result in increased costs, increased utilization of healthcare resources, higher complication rates, and poorer patient outcomes. Therefore, it is important that the orthopaedic community continues to progress toward improvising and expanding access to care for all patients.
Biomechanical Evaluation of an Augmented Medial Capsular Repair for Hallux Valgus Surgery
Authors: Miller Christopher P. , Paulus Megan , Kreulen Christopher , Harris Thomas , Giza Eric 
Published: October 2019

Category: Bunion Introduction/Purpose: Hallux valgus correction is often complicated by recurrence in the setting of inadequate soft tissue balancing. The etiology of recurrence is multifactorial, but a key factor is the quality of the medial capsulorrhaphy which is limited by the quality and strength of the soft tissues. These soft tissues are often attenuated with loss of integrity due to the longstanding bunion deformity. We hypothesize that the medial capsulorrhaphy augmented with a suture tape construct will create a stronger repair. Methods: 8 unmatched and 16 matched cadaveric foot specimens were prepared. None had bunion deformities. The 8 unmatched samples were tested to determine the strength of the native medial capsule. The 16 matched samples underwent a longitudinal medial capsulotomy, eminence resection and medial capsulorrhaphy with or without augmentation with a suture tape construct. The samples were then tested in a biomechanics lab to determine the strength of the medial capsulorrhaphy. Results: The mean maximum moment for the intact, capsular repair and suture tape groups were 2.19 ± 0.639 Nm, 0.225 ± 0.074 Nm and 0.968 ± 0.581, respectively, P<0.001. The mean stiffness for the intact, capsular repair and suture tape groups were 8.06 ± 3.75 N/mm, 1.463 ± 0.553 N/mm, and 4.438 ± 4.035 N/mm, respectively, P=0.003. The suture tape provided 4.3x higher maximum moment and 3x higher stiffness compared to traditional medial capsulorrhaphy. Conclusion: The study demonstrates that a medial capsular repair augmented in a cadaveric model of medial capsulorrhaphy to provide greater strength compared to conventional suture repair. Recurrence of hallux valgus after surgery is multifactorial. One element is the strength of the medial imbrication and capsular repair at the 1st metatarsal phalangeal joint (MTPJ). The study presents biomechanical data demonstrating that this repair is strengthened with suture tape augmentation at the medial 1st MTPJ. This may result in decreased recurrence and potentially improved patient satisfaction following bunion correction.
Dynamic First Tarsometatarsal Instability During Gait Evaluated by Pedobarographic Examination in Patients with Hallux Valgus
Authors: Min Byung Jo , Koo Seungbum , Park Won-keun , Kwon Ki-bum , Lee Kyoung Min 
Published: October 2019

Category: Midfoot/Forefoot Introduction/Purpose: This study aimed to investigate the pedobarographic characteristics of tarsometatarsal instability and to identify factors associated with pedobarographic first tarsometatarsal instability in patients with hallux valgus deformity. Methods: Fifty-seven patients (mean age, 59.7 years; standard deviation, 11.4 years; 6 men and 51 women) with a hallux valgus angle (HVA) greater than 15° were included. All patients underwent a pedobarographic examination along with weight-bearing anteroposterior (AP) and lateral foot radiography. Radiographic measurements were compared between the two groups with and without pedobarographic first tarsometatarsal instability. The association between the radiographic and pedobarographic parameters of the first tarsometatarsal instability was analyzed using the chi-square test. Binary logistic regression analysis was performed to identify significant factors affecting pedobarographic first tarsometatarsal instability. Results: HVA (p<0.001), the intermetatarsal angle (p=0.001), and AP talo-first metatarsal angle were significantly different between the pedobarographically stable and unstable tarsometatarsal groups. There was no significant association between radiographic and pedobarographic instabilities of the first tarsometatarsal joint (p=0.924). HVA was found to be the only significant factor affecting pedobarographic tarsometatarsal joint instability (p=0.001). Conclusion: The pedobarographic examination has possible clinical utility in evaluating first tarsometatarsal joint instability in patients with hallux valgus deformity. Patients with greater HVA need to be carefully monitored for the presence of first tarsometatarsal instability, and the necessity of the Lapidus procedure should be considered.
MRI Analysis for Clarification of Mechanism of Ankle Osteoarthritis: When the Talar Tilt Exceeds 15 Degrees, the BME Pattern of the Ankle Are Changes
Authors: Mitsui Hiroyuki , Hirano Takaaki , Akiyama Yui , Endo Wataru , Karube Tomoko , Haraguchi Naoki , Niki Hisateru 
Published: October 2019

Category: Ankle Arthritis Introduction/Purpose: In recent years, total ankle arthroplasty (TAA) has been widely performed for severe ankle osteoarthritis (OA). However, TAA is not always successful in cases of advanced varus; in fact, some researchers have stated caution regarding its indication. Previously, to elucidate the pathological condition of ankle OA using MRI, we investigated that confirmed the existence of an association among the Takakura–Tanaka classification, foot and ankle alignment, and bone marrow edema (BME). In this study, we focused on the talar tilt angle and compared the cases of terminal ankle OA as per Takakura– Tanaka classification (stage 3b and 4) wherein this angle exceeded 15° with those wherein it did not exceed in terms of the mode of BME onset. Methods: Of 616 cases of ankle OA diagnosed in our hospital between May 2009 and January 2018, we examined the MRI images of 52 feet of 50 patients diagnosed with severe ankle OA. The talar tilt angle with the ankle under load was measured using frontal X-ray, following which the presence/absence of BME was determined by dividing the talus, subtalar, and Chopart’s joints into 22 regions (areas 1–11 and 1’–11’). In statistical analysis, we first obtained the total number of BME incidences for each case. Then, after dividing this disease group into severe varus (SV; talar tilt angle = 15° or more) and mild varus (MV; talar tilt angle < 15°) groups, we compared t-test scores for the respective BME incidence rates. Furthermore, we used Fisher’s exact test to examine differences in terms of BME incidence rates between the two groups for each subdivided region. Results: No significant differences were found between the two groups in terms of BME incidence rates for each case. However, the rates in each area were significantly lower in the SV group than in the MV group for area 2 (SV group, 14%; MV group, 57%) and area 4 (SV group, 7%; MV group, 39%), i.e. the SV groups corresponding to the outer surface of the trochlea talar. Conversely, in the subtalar joint, the rates were significantly higher in the SV group than in the MV group for area 10 (SV group, 36%; MV group, 11%) and area 10’ (SV group, 29%; MV group, 5%), i.e. the medial surface of the calcaneus. Conclusion: In cases of severe ankle OA wherein the talar tilt angle exceeds 15°, the load exerted on the outer side of the talus decreases in the talar joint, whereas a greater load is exerted on the medial subtalar joint located at the innermost side in the subtalar joint. Differences in terms of the mode of BME incidence in the subtalar joint, which is not replaced with normal TAA, may be a poor prognostic factor for postoperative TAA.
Early Weight-Bearing Does Not Compromise Postoperative Healing in Jones Fracture ORIF
Authors: Moraes Leonardo V. M. , Kelly Stéfani C. , Jones James R. , McKissack Haley , Jha Aaradhana J. , Hsu Alan , Chinnakkannu Karthikeyan , Wilson John T. , Naranje Sameer M. , Shah Ashish B. 
Published: October 2019

Category: Midfoot/Forefoot, Trauma Introduction/Purpose: Several controversies persist regarding fracture treatment of the fifth metatarsal base. Due to its low blood supply, Jones fracture has an inherent difficulty of consolidation, and may devolop complications such as delayed union, non- union and refracture. Usually the Jones fracture treatment is done with extended period of non-weightbearing with either nonoperative or operative treatment. The surgery is indicated particularly in athletes or in the setting of nonunion or fracture displacement. The purpose of the present retrospective case series is to assess postoperative outcomes among patients who weight bear earlier than standard practice. Methods: We performed a retrospective analysis of the medical and radiographic records from patients who had undergone operative IM fixation of an acute isolated Jones fracture from May 2013 and August 2018. Patients were permitted to weight- bear as tolerated. Demographic information, such as age, gender, body mass index, the use of tobacco, presence of medical comorbidities, and the time of radiographic union were evaluated. Standardized radiographs at 2 weeks, 6 weeks, 3 months and 6 months after surgeries were chosen for evaluation. Radiographic union was defined as bridging in 2 of 3 (medial, lateral, plantar) cortices. Results: Twenty one patients were included for analysis. Of these, 14 had at least one comorbidity present at time of operation. Average BMI was 37.6, and average age was 44.8. One patient (4.8%) was lost to follow up, and therefore did not have radiographic results available for review at any appointment. At 6 weeks, 16 of 21 patients showed signs of radiographic healing; 8 were completely healed, and 8 were incomplete. One patient (4.8%) had nonunion, which was documented at 6 week, 3 month, and 6 month readings. None of the 21 patients experienced any other postoperative complications, including infection, wound dehiscence, sepsis, DVT, implant failure, or need for revision surgery. Conclusion: Patients who were subjected to early weight-bearing after fifth metatarsal Jones fracture surgery had satisfactory fusion rates with no additional postoperative complications, even despite having high average BMI and multiple comorbidities. We believe that patients can be treated with early weightbearing as tolerated after operative fixation of an acute Jones fracture, and achieve satisfactory outcomes comparable those associated with traditional postoperative protocols.
Anatomical Study of Saphenous Nerve and Great Saphenous Vein Using a Peripheral Vein Illumination Device and Ultrasonography
Authors: Ota Yuki , Nakasa Tomoyuki , Ikuta Yasunari , Tsuyuguchi Yusuke , Kanemitsu Munekazu , Adachi Nobuo 
Published: October 2019

Category: Ankle, Basic Sciences/Biologics Introduction/Purpose: Usefulness of ultrasonographic guided saphenous nerve block is well known for perioperative pain management of foot and ankle surgery. However, in some cases it may be impossible to identify the saphenous nerve, especially women or obese patients, so successful rate of ultrasonographic guided saphenous nerve block was reported 70 to 80%. Previous reports demonstrated that the saphenous nerve is running adjacent to the greater saphenous vein, which suggests that the greater saphenous vein can be an indicator to identify the saphenous nerve. The purpose of this study was to examine anatomical relationship between the saphenous nerve and the greater saphenous vein which is depicted using the near-infrared (NIR) vascular imaging system, the Vein Viewer Flex®. Methods: Thirty legs as 15 healthy subjects (13 males, 2 females) were included in this study. Average age was 34.2 ± 3.2 years old. In a supine position, the knee joint was flexed 60 degrees with mild flexion, abduction, and external rotation of the hip joint, and the greater saphenous vein was depicted using the Vein Viewer Flex® on the skin of the lower extremity. The vein visualized as a green light was then marked using the skin marker. (Figure 1). After marking the greater saphenous vein, the greater saphenous vein and saphenous nerve were identified under ultrasonography at 5 cm distal from the medial knee joint space (Figure 2). The distance between the greater saphenous vein which was marked using the Vein Viewer Flex® and the saphenous nerve was measured in the ultrasonography images. The circumference of the leg (COL) was also measured. Results: The course of the greater saphenous vein could be depicted by the Vein Viewer Flex® in all cases, and it was confirmed by ultrasonography. It was confirmed that the saphenous nerve was located under the sartorius fascia and it was running posteromedially in parallel of the greater saphenous vein. The mean distance from the saphenous nerve and the greater saphenous vein was 7.9 ± 2.7 mm. There was no significant difference between left and right legs (right: 7.9±2.8 mm, left: 8.0±3.0 mm, P=0.95). The mean COL was 34.2 ± 1.9 mm, and there was a moderate positive correlation (r = 0.45). Conclusion: This study revealed that the saphenous nerve is running in parallel of the greater saphenous vein which can be depicted by the Vein Viewer Flex®. Ultrasonography after depicting greater saphenous vein enabled to confirm the saphenous nerve with certainly and noninvasive. These findings suggested that the combination of the Vein Viewer Flex® and ultrasonography enables the saphenous nerve block to be more reliable procedure even the saphenous nerve is hardly identified by the ultrasonography.