bluuebunny/crossref_metadata_2025_split huggingface dataset:
Subtalar Arthroereisis as an Adjunct Procedure Improves Forefoot Abduction in Stage IIb Adult- Acquired Flatfoot Deformity
Authors: Bernasconi Alessio , Argyropoulos Miltiadis , Patel Shelain , Ghani Yaser , Cullen Nicholas , Singh Dishan B. , Welck Matthew J. 
Published: November 2020

Category: Hindfoot; Midfoot/Forefoot Introduction/Purpose: Our aims were: (i) to determine whether subtalar arthroereisis (STA) as adjunct procedure improved radiographic correction of stage IIb adult acquired flexible flatfoot deformity (AAFD); (ii) to assess the STA-related complication rate. Methods: A retrospective analysis of 22 feet (21 patients) diagnosed with stage IIb AAFD treated by medialising calcaneal osteotomy (MCO), flexor digitorum longus (FDL) transfer, spring ligament (SL) repair with or without Cotton osteotomy and with or without STA in a single institution was carried out. Seven measurements were recorded on pre and postoperative (minimum 24 weeks) radiographs by two observers and repeated twice by one. Inter and intraobserver reliability was assessed. The association of demographic (gender, side, age, BMI) and surgical variables (Cotton, STA) with radiographic change was tested with univariate analysis followed by a multivariable regression model. Results: Excellent inter and intraobserver reliability was demonstrated for all measurements (ICC range, 0.75-0.99). Multivariable regression showed that STA was the only predictor of change in talo-navicular coverage angle (TNCA) (R2=0.31; p=0.03) and in calcaneo-fifth metatarsal angle (CFMA) (R2=0.40; p=0.02) on dorsoplantar view. STA was associated to a greater change in TNCA by 10.1 degrees and in CFMA by 5 degrees. Four patients out of 12 STA complained of sinus tarsi pain after STA, and removal of the implant resolved symptoms in 3 of them. Conclusion: In this series, STA as an adjunct procedure to MCO, FDL transfer, SL repair in the treatment of stage IIb AAFD led to improvement in correction of forefoot abduction. STA-related complication and removal rates were 33%.
Use of Intramedullary Locking Nail for Displaced Intraarticular Fractures of the Calcaneus: What is the Evidence?
Authors: Bernasconi Alessio , Iorio Paolino , Ghani Yaser , Argyropoulos Miltiadis , Patel Shelain , Welck Matthew J. 
Published: November 2020

Category: Trauma Introduction/Purpose: There is increasing interest on how to best manage displaced intraarticular calcaneal fractures (DIACF). Intramedullary locking devices (ILDs) have recently been advocated since the technique adopts a minimally invasive approach which may minimise complications and therefore improve outcomes. We reviewed the literature of commercially available devices to identify their characteristics, efficacy and safety. Methods: Medline, Scopus and EMBASE databases were searched to identify studies reporting use of ILDs for treating DIACF. A PRISMA checklist was used to sort eligible studies. Technical notes and biomechanical studies were first reviewed. Cohort studies were then reviewed for demographics, surgical technique, postoperative protocol, clinical and radiographic scores, complications and reoperations. The modified Coleman Methodology Score (CMS) was used to assess the quality of studies. Results: Thirteen studies investigated two devices (Calcanail; C-Nail). Four technical notes described how to use these devices and three biomechanical studies proved they offered adequate primary stability, stiffness, interfragmentary motion and load to failure. Seven clinical studies (302 feet, 289 patients) demonstrated satisfactory clinical (AOFAS, VAS) and radiographic (Bohler’s angle, Gissane angle, Goldzak index, posterior facet step-off) outcome at 16-months average follow-up. Metalware irritation (up to 20%) and temporary nerve entrapment symptoms (up to 30%) were the most common complications; soft tissue issues were reported in 3-5% of cases. Conversion to subtalar fusion was necessary in 4-6% of cases. Four (57%) studies were authored by implant designers and in 5 (71%) relevant conflict of interest were disclosed. Mean CMS was 61 (moderate quality). Conclusion: Treating DIAFCs with ILDs leads to satisfactory clinical outcomes at short term follow-up, enabling restoration of calcaneal height and improved subtalar joint congruency. Metalware irritation and temporary nerve entrapment symptoms are common complications although wound complications including infection and wound breakdown are less frequent than after open lateral approaches. The quality of evidence provided so far is only moderate and biased by potential conflict of interest, raising concerns about the generalisability of results.
Diagnosing the Impact of the Syndesmotic Injury on Lateral Ankle Stability using Dynamic Ultrasound
Authors: Bhimani Rohan , Saengsin Jirawat , Sato Go , Hagemeijer Noortje , Lubberts Bart , Guss Daniel , Waryasz Gregory R. , DiGiovanni Christopher W. 
Published: November 2020

Category: Ankle; Basic Sciences/Biologics; Sports; Trauma Introduction/Purpose: There is a high prevalence of coexisting lateral ankle ligament injuries and syndesmotic ligamentous injuries. However, it is unclear whether syndesmotic ligaments directly contribute toward the stability of the lateral ankle. Dynamic ultrasonography (US) is an imaging modality increasingly used for the care of orthopaedic foot and ankle patients because it allows dynamic evaluation of structures at the point of care with little risk to the patient and at low-cost. The aim of this study is to assess the effect of syndesmotic injury as well as combined syndesmotic and lateral ankle injury on the stability of the lateral ankle. Methods: Sixteen fresh frozen above-knee amputated cadaveric specimens, divided into two groups, underwent ultrasound evaluation for lateral ankle stability. In both the groups, the assessment was first done with all ligaments intact and later with sequential transection of anterior inferior tibiofibular ligament (AITFL), interosseous ligament (IOL), posterior inferior tibiofibular ligament (PITFL), anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL) and posterior talofibular ligament (PTFL). In all scenarios, two loading conditions were considered: (1) Anterior drawer test: 50N and 80N and (2) Lateral clear space (LCS): 1.7Nm torque. The talar translation and LCS to the fixed tibial plafond were measured using Image J. Wilcoxon rank-sum test was used to compare the findings of each ligamentous transection state to the intact state. A p-value <0.05 was considered statistically significant. Results: In group 1 after transection of the all syndesmotic ligament and ATFL, an increase in the anterior drawer and lateral clear space values were found as compared to the intact state. Similarly, in group 2 the anterior drawer and lateral clear space values significantly increased after transection of the AITFL and ATFL as compared to the intact state (p-values = 0.01). Conclusion: Ultrasound can be used to evaluate the impact of the syndesmotic injury on lateral ankle stability while performing dynamic stress maneuvers. Lateral ankle instability appears after injury to all syndesmotic ligaments and ATFL, or after one syndesmotic ligament rupture (AITFL) with a concomitant anterior talofibular ligament rupture (ATFL). These findings suggest that surgeons should lower their threshold for stabilizing the syndesmosis if there is a concomitant lateral ankle ligament injury. [Table: see text]
Using Area and Volume Measurements on Weightbearing CT to Detect Isolated Lisfranc Instability
Authors: Bhimani Rohan , Sornsakrin Pongpanot , Ashkani-Esfahani Soheil , Lubberts Bart , Waryasz Gregory R. , Guss Daniel , DiGiovanni Christopher W. 
Published: November 2020

Category: Midfoot/Forefoot; Sports; Trauma Introduction/Purpose: Early detection of Lisfranc instability is critical for optimizing clinical outcomes. Injuries causing a more subtle instability, however, can be difficult to diagnose. The aim of this study was to compare the injured Lisfranc joint to the healthy contralateral side using weightbearing computed tomography (CT) in patients with known Lisfranc instability. We also aimed to define the range of normal measurement variation by comparing the Lisfranc joint measurements between the left and right foot in individuals without foot injury who underwent similar imaging. Our hypothesis was that compared to the healthy contralateral side, weightbearing CT area and volume measurements were increased in patients diagnosed with subtle Lisfranc instability. Methods: Patients with unilateral Lisfranc instability requiring operative fixation (n = 14) underwent preoperative bilateral foot and ankle weightbearing CT. A separate group of patients without foot injury who also underwent similar imaging were included as comparative controls (n = 36). For each weightbearing CT, 2 dimensional axial and coronal plane Lisfranc joint parameters, Lisfranc area, intercuneiform area, C1-M2 distance, C1-C2 distance, M1-M2 distance, first and second tarsometatarsal (TMT 1 and 2) alignment; and first and second tarsometatarsal (TMT 1and 2) dorsal step off were measured to evaluate the Lisfranc anatomy at a level 10 mm below the dorsal surface of medial cuneiform (Figures I and II). In addition, the volume of the Lisfranc joint was also evaluated. Values were recorded by two independent observers to assess interobserver reliability. Results: Among those with unilateral Lisfranc instability, values differed largely between the injured and the healthy contralateral side for all measurements performed (p-value range, 0.008 - <0.001). In the control population without foot injury, no differences were identified between any of the bilateral measurements (p-value range, 0.121 - 0.984). Conclusion: Weightbearing CT can effectively differentiate Lisfranc instability from those without instability. The Lisfranc volume and area had the largest difference between the injured and the uninjured feet among surgically treated patients with substantial interrater agreement making them the most relevant parameters for detecting Lisfranc instability. However, prospective studies are needed to validate the role of weightbearing CT in the diagnosis of subtle Lisfranc instability.
Achilles Injury and Access to Care in South Florida
Authors: Boden Allison , Geller Joseph S. , Granger Caroline , Summers Spencer H. , Kaplan Jonathan R. , Aiyer Amiethab A. 
Published: November 2020

Category: Hindfoot; Ankle Introduction/Purpose: Achilles Tendon (AT) rupture is the most common tendon rupture in the lower extremity with an incidence of 2.1 AT ruptures per 100,000 person years. Due to the non-emergent nature of this injury, a delay in presentation may occur leading to delays in diagnosis and treatment; which may alter both nonoperative and operative management. Health insurance status may directly impact time to presentation for many patients. To our knowledge, no study has evaluated the effect of insurance status on delay in diagnosis and treatment of AT rupture. Methods: From December 2013 to December 2018, 89 patients with AT ruptures who underwent surgical management were identified by CPT code in a dual-institution retrospective chart analysis. Demographic and injury-specific data were obtained with attention to the date of injury, date of diagnosis, location of initial presentation (clinic vs. emergency room), and number of medical visits. A univariate two tail t test was used to compare various groups. Statistical significance was set at p < 0.05 to determine the effects of insurance type on the time to diagnosis and treatment of acute AT ruptures. Results: When compared to adequately insured patients (private and Medicare), underinsured patients (uninsured and Medicaid) experienced a significantly greater time from the date of: injury to first clinic visit (14.5 days versus 5.2 days, p < 0.001), first clinic visit to surgery (34.6 days versus 4.8 days, p < 0.002), injury to surgery date (48.9 days versus 9.8 days, p < 0.001), initial presentation to when magnetic resonance imaging (MRI) was obtained (48.1 days versus 1.9 days, p < 0.002), and initial presentation to diagnosis (22.8 days versus 1.71 days, p < 0.029). Conclusion: Disparities in access to care are intimately related to insurance status. Uninsured and medicaid patients are subject to institutional delays and decreased access to care when compared to patients with private insurance. Under and uninsured patients are significantly more likely to present to the emergency department for their initial visit, potentially resulting in increased healthcare costs. Emergency department visits as well as difficulty in obtaining an appointment with an orthopedic surgeon may directly contribute to delay in diagnosis.
Quantitative Analysis of Talar Dome Morphology
Authors: Borchard Justine , Stevens Wilshaw , Siebert Matthew , Shivers Claire , Zide Jacob R. , Riccio Anthony , Francis Kirsten Tulchin- 
Published: November 2020

Category: Ankle; Other Introduction/Purpose: A flat-top talar dome deformity can alter ankle mechanics and impact daily activities. Radiographic determination of flatness is difficult using traditional measures. The purpose of this study is to describe a new method to quantify the talar dome morphology using lateral radiographs and a custom-written image processing algorithm. Methods: Skeletally mature patients previously treated for idiopathic clubfeet were identified from our institution’s clubfoot registry. All patients had weight-bearing lateral foot radiographs. Measurements included radius of curvature (ROC) of the talar dome and tibial plafond, talar length and height, and alpha angle. The ratio of the radii of the talar dome and tibial plafond (TD/TP Ratio) was determined. Custom-written, image processing MATLAB code was used to identify the talus from the lateral radiograph. Following manual identification of the articular surface, the average slope of the anterior, central, and posterior regions of the talar dome were calculated. Talar dome flatness was determined as the slope variance across all three regions. Higher variance indicated a rounder talar dome morphology, lower variance indicated a flatter dome. Inter-rater reliability of radiographic measures and the MATLAB based talar dome flatness were determined. Spearman’s rho was used to determine correlations between radiographic and MATLAB flatness measures. Results: For radiographic measures, the Inter-rater reliability (IRR) was determined for 52 feet. IRR was near perfect for the ROC of the talar dome (ICC=.985), talar length (ICC=.952), and alpha angle (ICC=.928). Measurement of the radius of the tibial plafond (ICC=.827) and talar height (ICC=.893) were reproduced with excellent reliability. The IRR of the TD/TP ratio was moderate (ICC=.608). Preliminary IRR for the MATLAB-based talar dome flatness (15 feet) was excellent (ICC=0.895). Flatness was strongly correlated with ROC of the talar dome (r=.621, p=.013), alpha angle (r=.557, p=.031) and TD/TP Ratio (r=-.589, p=.021). Conclusion: Flatness of the talar dome can be difficult to describe, as there lacks a single measure to accurately define its morphology. The method developed in this study was quick to apply (less than 5 to 10 minutes per foot) and had high inter-rater reliability.
A Retrospective Chart Review to Examine Intra-Compartment Pressures and Post-Operative Outcomes of Chronic Exertional Compartment Syndrome
Authors: Brower Jacob , Shuster David M. , Cheney Nicholas A. , Clark Brian C. 
Published: November 2020

Category: Other Introduction/Purpose: Chronic exertional compartment syndrome (CECS) is defined as reversible, insufficient blood supply to a fascial compartment’s contents. Patients with this condition have abnormally elevated pressures within specific fascial compartments, causing decreased blood flow to that area. This temporary loss of blood supply produces a feeling of tightness in the affected muscles, pain, and possibly local paresthesia. Surgical treatment involves a fasciotomy, which releases the implicated compartment’s fascia. This procedure creates additional space for muscle expansion and more adequate blood supply to the appropriate tissues.The purpose of this study is to review the surgical outcomes of patients diagnosed with lower extremity CECS whom received a fasciotomy, assessing correlations between resting intramuscular compartment pressures and surgical outcomes. Methods: A retrospective chart analysis was performed of the senior author’s patients between January 1st, 2013 and June 30th, 2019. Patients included in this study presented with symptoms consistent with lower extremity CECS and had the diagnosis confirmed, either unilaterally or bilaterally, via the resting intramuscular pressure cutoff (>=15 mmHg) outlined by the Pedowitz criteria. These patients subsequently received fasciotomies for the syndrome. Results: Out of the 37 patients included in this study, 30 (81.1%) reported improvement in their post-operative pain scores. There was a trend (P > 0.1523) between resting intra-compartment pressures and post-operative pain improvement. Conclusion: Our study suggests a positive trend between higher resting intra-compartment pressures and post-operative pain improvement. Due to the limited number of study participants, no correlations could be determined. However, this data is significant because it demonstrates the importance of the Pedowitz diagnostic criteria, as it is the first study showing a relationship between the resting pressure criteria and surgical outcomes. Further research is necessary to determine if there is a correlation between higher intramuscular pressures and positive surgical outcomes.
Osteochondral Lesions of the Tibial Plafond: A Systematic Review
Authors: Butler James J. , Rosas Kevin , Hurley Eoghan T. , Kennedy John G. 
Published: November 2020

Category: Ankle; Sports; Trauma Introduction/Purpose: Osteochondral lesions of the talus (OLTs) account for the majority of osteochondral lesions (OCLs) of the tibiotalar joint, with osteochondral lesions of the tibial plafond (OLTP) being less commonly reported. The purpose of this systematic review was to evaluate the topographical characteristics of OLTPs, and outcomes following surgical intervention. Methods: A systematic review of the MEDLINE, EMBASE and Cochrane Library databases was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies reporting clinical data for OLTPs were included. The level and quality of evidence of the included studies was evaluated using the Modified Coleman Methodology Score. Results: Nineteen studies with 395 OLTPs were included. Overall, 75.9% of OLTPs were associated with a traumatic history and/or previous ankle sprain. OLTPs were most commonly located in the centromedial region of the tibial plafond (30.4%), with the fewest number of OLTPs found in the anterolateral region of the tibial plafond (3.9%). In total, 46.9% of OLTPs were associated with co-existing osteochondral lesions of the talus. Microfracture was the most frequently utilised surgical technique amongst the included studies, and reported good clinical outcomes at mid-term follow up. Four studies were level of evidence II and 15 studies were level of evidence IV. Conclusion: This systematic review has found that osteochondral lesions of the tibial plafond are not a rare clinical finding in the setting of ankle trauma and are often associated with co-existing osteochondral lesions of the talus. Clinical outcomes following arthroscopic intervention appear to produce good results in the mid-term, but the low level of evidence, poor quality of evidence, marked heterogeneity and underreporting of the data confounds any recommendation based on this systematic review.
Impact of COVID-19 Pandemic on Patients Perceptions of Safety and Need for Elective Foot and Ankle Surgery in the United States
Authors: Chan Jimmy , Chen Kevin K. , Choi Peter , Rojas Edward , Schipper Oliver N. , Aiyer Amiethab A. , de Cesar Netto Cesar , Amin Amgad M. Haleem , Kadakia Anish R. , Vulcano Ettore 
Published: November 2020

Category: Ankle; Ankle Arthritis; Arthroscopy; Bunion; Hindfoot; Lesser Toes; Midfoot/Forefoot; Sports Introduction/Purpose: With the development of the COVID-19 pandemic, elective foot and ankle surgeries were delayed throughout the U.S. to divert healthcare resources and limit exposure. Little is known about the impact of COVID-19 on patient’s willingness to proceed with elective procedures once restrictions are lifted and factors contributing to such decision. Methods: Patients across six U.S. Orthopedic Institutions who had their elective foot and ankle surgeries cancelled secondary to the pandemic were given a questionnaire. Specifically, patients were asked about their willingness to move forward with surgery once restrictions were lifted and if not why. Pain-level and pain medication use were also assessed. Univariate analysis was used to identify factors that contribute to patient’s decisions. Results: A total of 150 patients participated in this study. N=21 (14%) opted not to proceed with surgery once restrictions were lifted. 43% (N=9) listed concern for COVID infection as the reason, however, 14% of them would proceed if procedures were performed in surgery center. Twenty-nine (19% of the total cohort) patients had increased pain and 11% of patients were taking more pain meds because of the delay to their procedure. Patients who decided not to proceed with surgery reported pain reduction (3% vs. 14%) and lower increase in pain medication used (5% vs. 12%). Conclusion: COVID-19 has made a significant impact on the healthcare. Delay of elective foot and ankle procedures impact patient quality of life and outcomes. Access to surgery centers may provide a partial solution during the pandemic.
Minimally Invasive Correction for Symptomatic, Fixed Curly Toe Deformity
Authors: Choi Jun Young , Suh Jin Soo 
Published: November 2020

Category: Lesser Toes Introduction/Purpose: Curly toe deformity is a relatively common deformity that generally occurs at the 4th and 5th proximal and/or middle phalanges but rarely presents with symptoms. Although numerous open operative techniques have been introduced, there is no established treatment yet. We report the results of minimally invasive correction for symptomatic, fixed curly toe deformity. Methods: Between 2016 and 2018, 25 consecutive percutaneous dorsolateral closing wedge-shaped osteotomies with Shannon burrs at the proximal and/or middle phalanx were performed. We assessed the postoperative clinical and radiological changes at a mean of 22.51 months of follow-up. Results: The locations of osteotomy were at the middle phalanx in 10 cases, proximal phalanx in 13 cases, and both in one case. The mean amount of corrections of varus inclination and shortening were 16.54° and 2.24 mm, respectively. The Foot and Ankle Ability Measure Activities of Daily Living scores significantly improved from 59.09 preoperatively to 74.55 at the last follow-up. There was one case of pin site infection and one case of incision site numbness due to digital nerve injury. Conclusion: Minimally invasive dorsolateral closing wedge-shape osteotomy is a simple, safe, and effective correction for symptomatic, fixed curly toe deformity.