bluuebunny/crossref_metadata_2025_split huggingface dataset:
Screw Fixation of the Posterior Malleolus Fragment in Ankle Fracture: Cadaveric and Clinical Studies
Authors: Lee Gisoo , Kang Chan , Won Yougun , Song Jae Hwang , Cho Byungki 
Published: October 2019

Category: Ankle, Trauma Introduction/Purpose: Previously, a posterior malleolus fragment (PMF) covering 25–30% of the articular surface was a known indication for surgical fixation for ankle fractures. This study aimed to compare the outcomes of screw fixation for PMF comprising <25% of the articular surface and to evaluate the results of cadaver experiments. Methods: The clinical study enrolled ankle fracture patients with PMFs who planned to undergo surgery between March 2014 and February 2017. Among them, 62 with type 1 PMF comprising <25% of the articular surface were included: 32 patients underwent cannulated screw fixation for PMF after fixation for lateral and/or medial malleolar fracture (A group), whereas the other 30 patients underwent internal fixation for lateral and/or medial malleolar fracture but no screw fixation (B group). Clinical outcomes were determined at the 3-, 6-, 12-, and 18-month visits. Additionally, cadaver studies were conducted to evaluate cannulated screw fixation or no fixation in cases of PMFs comprising <25% of the articular surface and >1 mm displacement. Ankle joint stability was measured under external torque on the ankle in the neutral position. The level of significance was set at P < .05. Results: Clinical outcomes at 6 and 12 months after surgery were significantly higher in group A than in group B. However, there was no significant intergroup difference in clinical outcomes at 18 months of follow-up. In the cadaver study, PMF screw fixations were significantly more stable under external rotation force. Conclusion: Screw fixation was significantly useful during early recovery and in short-term clinical outcomes owing to stabilization of ankle fractures with PMF involving <25% of the articular surface.
Changes in the Mechanical Axis and Weight-Bearing Line of the Ankle After Varus Knee Correction
Authors: Lee Seung Yeol , Kwon Soon-Sun , Lee Kyoung Min 
Published: October 2019

Category: Ankle, Hindfoot Introduction/Purpose: Varus limb malalignment results in an imbalance of force transmission to the knee joint, resulting in a concentrated load in the medial compartment. A varus knee correction may affect the ankle and subtalar joint, because the weight-bearing load on the lower extremity extends from the hip to the foot. A previous study suggested that the true mechanical axis of the lower limb should be calculated with a line from the center of the femoral head to the lowest point of the calcaneus, not to the center of the tibial plafond. Therefore, we performed this study to evaluate changes in the mechanical axis and weight- bearing line of the ankle after varus knee correction. Methods: Patients with a varus knee who were followed-up after they had undergone high tibial osteotomy (HTO) or total knee replacement arthroplasty (TKA) at an age of >20 years, and who had undergone preoperative and postoperative scanogram were included in this study. The hip-knee-ankle (HKA) angle, mechanical axis, and weight-bearing line (line from the center of the femoral head to the lowest point of the calcaneus) were measured on the radiographs. The point at which the mechanical axis and weight-bearing line passed through the tibial plafond was the ankle joint axis point. The postoperative change in the ankle joint axis point on the mechanical axis and weight-bearing line according to the HKA angle correction was adjusted by multiple factors using a linear mixed model. Results: A total of 257 limbs from 198 patients were included in this study. The preoperative HKA was 7.3 ± 4.7° and corrected to 0.4 ± 3.8°. Although the ankle axis points on both axes moved laterally after HTO and TKA, the ankle joint axis of the weight- bearing line showed a significant larger lateral movement (22.5±35.7%) (Fig.) than that of the mechanical axis (15.7±16.0%) in terms of rate of change (p = 0.006). The ankle joint axis point on the weight-bearing line moved laterally by 0.9% per degree of postoperative HKA angle decrease (p < 0.001). The change in the ankle joint axis point on the mechanical axis was not statistically significant after HTO and TKA (p = 0.223). Conclusion: The mechanical axis and weight-bearing line of the ankle moved laterally after the varus knee correction. The ankle joint axis on the weight-bearing line moved laterally as the HKA angle decreased after the surgery, whereas the varus knee correction did not significantly affect the ankle joint axis on the mechanical axis. The varus knee correction might affect the subtalar joint as well as the ankle joint. Therefore, we believe that our findings warrant consideration in pre- and postoperative evaluations using the weight-bearing line of patients undergoing varus knee correction.
Radiographic Analysis Between Two Commonly Used Measurements for Hallux Valgus Interphalangeus
Authors: Lever Caroline , Millward Graham , Mason Lyndon , Molloy Andrew 
Published: October 2019

Category: Bunion Introduction/Purpose: There is an increasing recognition of the contribution of hallux valgus interphalangeus (HVI) to the total deformity seen in hallux vallux valgus. The most commonly assessed radiological parameter is the hallux interphalangeus angle (HIA). Our aim in this study was to assess the reliability of the difference in medial and lateral proximal phalanx wall length (delta PP) in the assessment of hallux valgus interphalangeus in both the pre-operative and post-operative radiographs compared with the HIA. Methods: All patients undergoing scarf osteotomy for hallux valgus correction at our institution over a nine-month period were included. 40 feet in 36 patients were evaluated. Standard AP weight bearing radiographs preoperative and at 6 weeks post-surgery were evaluated by 2 independent observers. The standard PACS angular measurement tools were used for all measurements. The HIA and delta PP were measured along with hallux valgus angle (HVA) and intermetatarsal angle (IMA). Delta PP was calculated as the medial side length of the medial proximal phalanx minus the lateral side length of the proximal phalanx. SPSS 21 was used for statistical evaluation. Two-way random single measure intra-class correlation coefficient (ICC) was calculated to assess the interobserver agreement. Results: 33 female and 3 male patients were assessed. The mean age was 58 years (range 26-80 years). 18 patients underwent an Akin osteotomy. Pre-operative mean HVA 33 degrees, IMA 15 degrees, HIA 4 degrees and delta PP 1.64 mm. Post-operative mean HVA 17 degrees, IMA 9 degrees, HIA 7 degrees and delta PP 1.03 mm. In the sub group that underwent an Akin osteotomy the HIA increased from 5.2 degrees to 8.8 degrees in contrast to the delta PP that reduced from 2.04 to 0.26 mm. Pre-operatively the inter observer agreement using ICC was HVA 0.74, IMA 0.82, HIA 0.65 and Delta PP 0.70. Postoperatively the interobserver agreement was HVA 0.71, IMA 0.55, HIA 0.57 and Delta PP 0.64. Conclusion: The delta PP was more reliable than the HIA, with an improved interclass agreement on both pre and post- operative radiographs. The mean post-operative HIA increased, this was also present in the group where an akin osteotomy had been performed. In contrast the delta PP reduced. We feel pronation of the toe may alter the radiographic measures for HVI assessment and affect the validity of the HIA measurements, however the delta PP reliability was less affected. Pre-operative radiographs had greater interobserver agreement across all measures than postoperative radiographs, which may reflect difficulties in determining the bony landmarks for measurement following surgery.
Diabetic Ankle Fracture Complications: A Meta-Analysis
Authors: Lopez-Capdevila Laia , Ruh Juan Manuel Rios , Vidal Jorge Fortuño , Costa Andres Eduardo , Mata Mario Alexandre Sanchez , Fumas Alex Santamaria , Sevilla Alejandro Dominguez , Román-Verdasco Jorge , Perez Josep Miquel Sales 
Published: October 2019

Category: Ankle, Diabetes, Trauma Introduction/Purpose: Fractures in diabetic patients have a well-known increased risk of complications and this makes the decision to treat these fractures either surgically or conservatively a difficult choice. However, ankle fractures are mostly treated surgically because of their pattern and the postoperative management does not differ from those ankle fractures in non-diabetic patients. The following study aims to review the evident rate of complications following the treatment of an ankle fracture in diabetic patients and their matched controls. Methods: Searches of PubMed, Scopus, Cochrane and ISI Web of Knowledge were performed for studies published between the date of database inception and March 2018. An initial selection of 202 abstracts was performed by at least 2 different reviewers, of which 77 articles were selected to complete review. After following strict inclusion and exclusion criteria, only 17 papers were admitted to the final meta-analysis. Demographics patient characteristics and incidence of the overall and specific complications were extracted from each study selected and an odds ratio with a 95% confidence interval of each complication was calculated between the diabetic and non- diabetic groups. Major complications (infection, non-union, malunion, Charcot neuroarthropathy, amputation, death) were compared not only between the two main groups but also between subgroups (complicated diabetic and non-complicated diabetic patients, surgical and orthopaedic treatment). The statistics data was analysed by Stata 15. Results: There is a significant increased rate of complications after treating an ankle fracture orthopaedically or surgically in diabetic patients (OR 1.74, IC 95% 1.67 to 1.82). This risk is considerably higher when the ankle fracture is treated surgically (OR 5.14, IC 95% 2.79 -9.58). Among the complications in diabetic patients, the rate is greater in complicated diabetic patients (neuropathy, vasculopathy) compared to the non-complicated diabetic patients (OR 8, IC 95% 2.61 - 26.31). The main complication postoperative in ankle fracture described is infection, which is 7 times higher in diabetic patients in comparison to non-diabetic patients (OR 6.9, IC 95% 3.03 -15.73). The risk of amputation and/or non-union after an ankle fracture in diabetic patients is about 0.2%. Conclusion: This meta-analysis provides evidence that diabetic patients have a significant greater risk of presenting a complication after an ankle fracture. The rate of major complications (infection, malunion, non-union, amputation and death) is by far significantly higher among those diabetic patients treated surgically and even greater among complicated diabetic patients.
The Diagnostic Value of MRI for High Ankle Sprains with an Unstable Syndesmosis: Time to Scan Matters
Authors: Marsland Daniel , Randell Matthew , Ballard Emma , Forster Ben , Lutz Michael 
Published: October 2019

Category: Ankle, Arthroscopy, Sports, Trauma Introduction/Purpose: Early clinical examination combined with MRI following a high ankle sprain allows accurate diagnosis of syndesmosis instability. However, patients often present late, and for chronic injuries clinical assessment is less reliable. The aims of the current study were to describe MRI characteristics associated with diagnosed syndesmosis instability, and to assess if MRI characteristics change as the injury becomes chronic. Methods: Patients with a high ankle sprain and proven syndesmosis instability at arthroscopy were retrospectively identified from the logbooks of two fellowship trained foot and ankle surgeons over a five-year period. Patients were excluded if they had a distal fibula fracture or absence of an MRI report by a consultant radiologist. Associations between MRI characteristics and time from injury to MRI scan, categorised as acute (< 6 weeks), intermediate (6-12 weeks) and chronic (> 12 weeks) were examined using the Pearson’s chi-squared or Fisher’s exact tests (significance set at p<0.05). Results: Of the 164 patients, 108 had an MRI scan in the acute period, 32 were classified as intermediate and 24 as chronic. A posterior syndesmosis injury was detected in 93.5% of acute patients, 87.5% of intermediate patients and 54.2% of chronic patients. In the acute group, PITFL injury was detected in 78.7% of patients, posterior malleolus bone oedema in 60.2% and posterior malleolus fracture in 15.7%. The proportion of patients with injury to the PITFL in intermediate patients was 59.4% and 29.2% in chronic patients which was significantly lower than in acute patients (p<0.001). Twenty eight patients with posterior malleolus bone oedema had an apparently normal PITFL. The proportion of patients with posterior malleolus bone oedema or fracture were not significantly different between groups. Conclusion: The most important finding of the current study is that in acute high ankle sprains with syndesmosis instability, MRI detected a posterior syndesmosis injury in 93.5% of patients. Posterior malleolus bone oedema appears to be a marker of an unstable syndesmosis injury, regardless of time from injury to the MRI scan. The ability of MRI to detect a posterior syndesmosis injury reduces significantly if delayed more than 12 weeks. If suspicious of a high ankle sprain, we advocate early MRI assessment to help determine stable versus unstable injuries, as the ability of MRI to detect posterior injuries reduces over time.
Entry Point Safe Zone for Anteroposterior Screws in Posterior Malleolus Fracture Fixation: A Cadaver Study
Authors: McKissack Haley , Yu Jonathan , He Jun Kit , Montgomery Tyler , Moraes Leonardo , Dahlgren Nicholas , Shah Ashish 
Published: October 2019

Category: Ankle, Basic Sciences/Biologics, Trauma Introduction/Purpose: Percutaneous anterior-posterior (AP) screw is an option for posterior malleolus fracture fixation when the fracture fragment can be reduced indirectly by the means of ligamentotaxis. However, anterior anatomic structures could be injured during screw placement. We assessed this risk in cadavers. Methods: Eleven below-knee cadavers were employed for the placement of AP screws in an attempt of fixing assumed Haraguchi Type-I posterior malleolar fractures. Three entry point, medial, middle, and lateral, were selected as medial to the tendon of tibialis anterior (TAT), lateral to the TAT, and lateral to the extensor digitorum longus (EDL). On each cadaver, three AP screws were placed under the guidance of fluoroscopy. After dissection, measurements were made (mm) from each screw to nearby structures. Mean, minimum, maximum distances, and 95% confidence intervals were calculated. Instances of damage to the structures were recorded. Results: Mean, minimum, and maximum distances from the medial screw to the saphenous vein, TA, EHL, anterior tibial artery (ATA), and deep peroneal nerve (DPN), were 18.1 (12-25) mm, 2.0 (0-5) mm, 13.6 (9-20) mm, 16.6 (9-25) mm, and 20.1 (12-27) mm. From the middle screw to the ATA, DPN, TA, EHL, and EDL, were 1.2 (0-3) mm, 4.9 (3-9) mm, 3.8 (1-7) mm, 0.4 (0-2) mm, and 13.6 (10-18) mm. From the lateral screw to the superficial peroneal nerve (SPN), EDL, DPN, and ATA, were 10.8 (0-16) mm, 1.2 (0-4) mm, 15.9 (11-25) mm, 19 (15-27) mm. The SPN was found partially cut by the lateral screw on 1 specimen. The middle screws were adjacent to the ATA and DPN without damaging to them. Conclusion: Lateral and middle percutaneous AP screw placement put certain anatomic structures at-risk of injury. Medial screw placement did not result in appreciable damage to adjacent structures. Entry point of AP screws should be selected with respect to posterior malleolar fracture and anatomic structures. Meticulous dissection should be performed when placing anteroposterior screws.
Masquelet Technique for Hindfoot Fusion of Gustilo IIIA Open Ankle Dislocation with Complete Talar Extrusion and Loss
Authors: Miskiel Sandra A. , Caruso Steven A. , Pagliaro Andre J. 
Published: October 2019

Category: Hindfoot, Trauma, Ankle Introduction/Purpose: Complete talar extrusion is a rare injury resulting from high-energy trauma, with dissociation of the talus from surrounding bony and soft-tissue structures. Complications after complete talar extrusion include infection, osteonecrosis, posttraumatic osteoarthritis, and leg-length discrepancy. There is a lack of consensus on the optimal treatment algorithm for complete talar extrusion, due in part to high complication rates associated with injury and treatment. Thus, we report a staged treatment method utilizing the Masquelet Technique with temporary cement spacer, followed by bone grafting with use of femoral shaft autograft and bulk cancellous allograft. Methods: 44-year-old male status post high-speed motorcycle collision presented with left ankle Gustilo IIIC open fracture dislocation with complete talar extrusion and loss, concomitant ipsilateral tibial plateau fracture and metatarsal shaft fractures. Twelve weeks post-injury, after multiple staged debridements, external fixation and extensive wound vac treatments, removal of the left leg multi-planar external fixator was performed with left distal tibial, fibular, navicular and calcaneal articular and subchondral bone debridement in preparation for Masquelet procedure and pantalar fusion. Open reduction and realignment of left ankle and foot with intramedullary fixation with hindfoot fusion nail was performed, with placement of antibiotic cement spacer for development of secondary reactive periosteal membrane. After nine weeks, intramedullary bone reaming aspiration tool was utilized for removal of left femur intramedullary bone marrow for autograft. Hindfoot pantalar fusion was performed using ipsilateral femoral shaft autograft and bulk cancellous allograft in place of antibiotic spacer. Results: Patient went on successfully to fusion and had one transfixation screw removed during the course of his recovery. Patient was also treated using a long leg ankle foot orthosis brace as a stress shielding device during heavy labor. Patient returned back to work and heavy labor as a landscaper and has had no residual pain. At 24 months postoperative, patient achieved an AOFAS ankle-hindfoot score of 83/100 (good). Conclusion: To our knowledge, this is the first case of complete talar extrusion treated with a Masquelet procedure with ipsilateral femoral shaft autograft and bulk cancellous allograft. While chronic pain is reported in as many as 75% of patients post- complete talar extrusion, and infection rates as high as 88%, our patient reports no residual pain and did not experience a postoperative infection. This technique represents a reasonable approach and warrants consideration for the treatment of this rare, complex injury.
Anti-Gravity Simulated Weight Reduction: A Pilot Study to Assess the Impact Upon Pain for Foot and Ankle Arthritis
Authors: Morley William , Dawe Edward , Boyd Robert , Creasey James , Grice John , Marsland Daniel , Taylor Heath 
Published: October 2019

Category: Ankle, Ankle Arthritis, Hindfoot, Midfoot/Forefoot Introduction/Purpose: Osteoarthritis in the foot and ankle affects approximately 30,000 patients annually in the UK. Evidence has shown that excess weight exacerbates foot pain, with significant increases in joint forces. However, despite the current UK trend for Clinical Commissioning Groups to ration surgery for obese patients, studies have not yet determined the effect of weight loss in obese patients with foot and ankle arthritis. Methods: Following ethical approval, a prospective study of 19 obese patients (mean BMI 39.2, range 31.2 – 50.3) with foot and ankle arthritis was undertaken with funding from BOFAS. Under physiotherapist supervision, patients walked for one minute on an anti-gravity treadmill, which allowed simulated weight reduction. Following baseline assessment, reduced BMI was simulated, starting at 20, rising in increments of 5, until each patient’s usual BMI was reached. Pain was assessed using a Visual Analogue Scale (VAS). Repeated measures ANOVA was used to assess for significant changes in pain, comparing baseline with each simulated BMI category (significance set at p<0.05). Results: Simulated weight loss to BMI 25 caused a significant reduction in pain (p<0.05, power 0.91). Mean VAS pain scores improved by 46% (22.8 points, p=0.002) and 32% (15.9 points, p=0.04) for BMI categories 20 and 25 respectively, compared with baseline. Pain scores were not significantly different comparing between BMI categories of 25 and 20. Conclusion: Simulated weight loss to normal BMI significantly decreased pain in obese patients with foot and ankle arthritis. The use of the anti-gravity treadmill to demonstrate the feeling of normal BMI has also provided motivation to several patients to lose weight. The current study could be used to power future studies to investigate the effects of weight loss in foot and ankle patients.
Treatment of Avulsion Fractures of the Base of the Fifth Metatarsal with Walking Boot and Hard-Soled Shoes: A Comparative Study
Authors: Nishikawa Danilo Ryuko Cândido , Duarte Fernando Aires , Saito Guilherme Honda , Monteiro Augusto César , de Cesar Netto Cesar , Prado Marcelo Pires 
Published: October 2019

Category: Midfoot/Forefoot, Trauma Introduction/Purpose: Acute avulsion fractures of the base of the fifth metatarsal are common and usually treated non- surgically with satisfactory outcomes. Forms of conservative treatments are described such as elasticated bandaging, immobilization in a cast, walking boot and hard-soled-shoes. The aim of this study was to compare the clinical and functional outcomes, time to return to the previous activities, time and rate of fracture healing of the patients with avulsion fracture of the base of the fifth metatarsal treated in a hard-soled-shoes (HSS) or in a walking boot (WB). Our null hypothesis is that a less rigid immobilization without restriction of the ankle yields the same final results. Methods: A retrospective and comparative study of 72 patients with acute avulsion fractures of the base of the fifth metatarsal treated with the WB or the HSS, from March 2014 to November 2018. The average age of the patients was 41,25 (range, 11-88) and there were 56 female and 16, male. 39 were treated with the WB and 33, with the HSS. Patients with comorbities that could interfere in the rate and time of bony healing (diabetes and inflammatory joint disease), associated ankle ligament lesions and loss of follow-up were excluded. Patients were followed regularly until they were clinically asymptomatic and able to return to their previous activities (work, daily activities, sports). We retrospectively reviewed medical records containing the visual analogue scale (VAS) for pain and the american orthopaedic foot and ankle society (AOFAS) score of each visit as well as radiographic exams to evaluate time and rate of fracture healing. Results: Patients of both groups had similar VAS and AOFAS scores in 8 (p=0,34 and p=0,83) and 12 (p=0,25 and p=0,79) weeks. Age and gender distribution in the two groups were equal (p=0,23 and p=0,34, respectively). Time taken to return to the previous activities were not significant different between both groups, with the HSS group taking 8,33 weeks and the WB taking 9,73 weeks (p=0,10). The mean time for bone consolidation was significant higher in the HSS group, taking 8,64 weeks while in the WB took 7,18 weeks (p<0,001). Only 1 case of non-union was observed in the WB group and none in the HSS group. Conclusion: Our study concluded that avulsion fractures of the base of the fifth metatarsal can be treated equally with the HSS or the WB. Both types of immobilization showed to be equivalent in terms of clinical and function evaluation, return to the previous activities without difference in the rate of the fracture consolidation.