bluuebunny/crossref_metadata_2025_split huggingface dataset:
Deep Infiltrating Endometriosis is Frequent in All Stages of Endometriosis and the Depth of Infiltration Influences Surgical Parameters Proportionally
Authors: Hackethal Andreas , Luck Catharina , Konrad Lutz , Muenstedt Karsten , Tinneberg Hans-Rudolf , Oehmke Frank 
Published: September 2018

Background Deep infiltrating endometriosis (DIE) in contrast to superficial endometriosis is known to cause intense pain-related symptoms depending on the anatomic region and depth of infiltration. Despite the known impact of DIE, clinical comparison to superficial endometriosis is difficult to accomplish because no DIE classification is used regularly and the rASRM score does not consider DIE adequately. Methods We regularly use the ENZIAN classification to group DIE additionally to the rASRM score. The surgical treatment of patients without prior known endometriosis from January 2006 to December 2008 was evaluated in relation to the classification systems used. Results The study population included 100 patients and all were scored according to the rASRM score. Forty-two percent (42/100) presented with DIE and were additionally classified to the ENZIAN score. In all rASRM stages of endometriosis, a high rate of over 33% DIE was found with a maximum of 80% in stage 4 patients. Patient characteristics did not differ between patients with superficial EM and DIE. Laparoscopy was the main surgical approach regardless of the type of endometriosis. The presence of intra-abdominal adhesions, duration of excisional surgery and hospital stay correlated with the depth of infiltration according to the ENZIAN. Conclusions This is the first study to reveal that the presence of DIE is an unexpectedly frequent finding in all rASRM stages. Though patient characteristics do not differ between DIE and superficial EM, the surgical parameters for adequate excisional surgery are significantly different and proportionally influenced by the depth of infiltration.
Takedown of Ankle Fusions and Conversion to Total Ankle Replacements
Authors: Coetzee J. Chris , Nilsson Larry , Fritz Jacquelyn 
Published: September 2018

Category: Ankle Introduction/Purpose: With ankle replacements gaining credibility there is a small subset of patients that might benefit from a conversion of an ankle fusion to a replacement. There is not much in the literature about conversions and we began this study without having any specific data regarding success and expectations we could provide to the patients. Our hypothesis was that for the correct indication a conversion of an ankle fusion to a total ankle replacement might do as well as a primary total ankle replacement. Methods: Twenty five patients presented to the senior author with either ongoing ankle pain after a fusion, or increasing pain after a period of relative comfort after an ankle fusion. All patients came specifically with the desire to discuss a conversion to an ankle replacement. Exclusion criteria included a history of Diabetes, peripheral neuropathy, excision of either malleoli at the time of fusion, pantalar fusion and neurovascular compromise. This study was conducted in compliance and approved with a local IRB. Outcomes were evaluated pre-operatively and post-operatively with the Veterans Rand Health Survey (VR-12), Ankle Osteoarthritis Scale (AOS), Visual Analog Scale (VAS) Pain scale and the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score forms. A patient satisfaction survey was distributed to all patients and results were tabulated. Average follow up for outcome scores 23.77 months (range 4 – 74.78 months). Results: All ankle fusion conversions done at our center were included; no patients were lost to follow-up. Twenty-five patients(19 females) with the mean age of 63.7 months(36.55-75.83) were followed with a mean follow-up of 22.19 months(4–74.78 months). The mean AOFAS improved pre-operatively 26.25(8.0-56.0) to the latest follow-up of 78(77-100). VR-12 Mental improved from 52.24(34.81-72.46) to 56.13(28.4–72.31), and Physical 21.88(13.34-35.79) to 36.49(19.82-50.39) pre-operatively to post-operatively, respectively. The AOS Pain improved: 533.33(243-898) to the latest follow-up 215.86(15 -641); AOS Disability: 628.67(306-900) to the latest follow-up 221.64(2-612). Given patients have minimal to no dorsiflexion(DF) and plantarflexion(PF) with an ankle fusion, the range of motion increased with the affected ankle. Patients have a DF of 9.47degrees(2-15) and PF of 21.53degrees(12-35). Overall patients were satisfied with their results: 76.81/100. Conclusion: This is a small study with reasonable short follow-up, but the evidence show very satisfactory functional outcomes after a conversion of an ankle fusion to a total ankle replacement. Patient selection is extremely important. Long-term follow-up will show whether the longevity of these replacements compare to primary replacements.
Z-cut Osteotomy for Correction of Adult Acquired Pes Planovalgus Deformity
Authors: Ebaugh Michael , Larson David , Reb Christopher , Hyer Christopher , Berlet Gregory 
Published: September 2018

Category: Ankle Introduction/Purpose: Medial displacement calcaneus tuberosity osteotomy and anterior process lengthening calcaneus osteotomy are traditional single-plane osteotomy techniques used in adult acquired flatfoot deformity reconstruction. More recently, three plane step-cut osteotomies were described for each of these and offer improved rotational stability via the horizontal limb. However, a major technical challenge is achieving a sufficiently long horizontal limb to correct deformity through lengthening without losing bony apposition. Combining the anterior process and tuberosity step-cuts using an elongated horizontal limb (“Z-cut”, Figure 1) alleviates this technical challenge, creates a very large surface area for bony healing, and utilizes a single incision. We hypothesized that the Z-cut osteotomy achieves clinical and radiographic flatfoot deformity correction with a high union rate. Methods: This was an IRB-approved retrospective study of 17 patients who underwent Z-cut osteotomy for treatment of moderate to severe symptomatic adult acquired flatfoot deformity, Stage IIB. Mean follow up was 8.3 months. Radiographic correction was assessed via weight bearing radiographs taken pre-operatively and at a mean of 26 +/- 2 weeks post operatively. Measurements included Meary’s angle (talo-1st metatarsal angle), talonavicular joint (TN) uncoverage percentage, TN incongruency angle, medial cuneiform to fifth metatarsal height, and calcaneal pitch. Union rates, calcaneocuboid joint arthritic changes and clinical outcomes via Foot Function Index (FFI) score were assessed preoperatively and at a mean of 29 months following surgery. Paired t-test was used to compare both clinical and radiographic outcomes with statistical significance set at p<0.05. Results: Nine patients returned an FFI questionnaire with a mean improvement of 52.1 to 10.3 (p = .002). Calcaneal pitch improved from 13.2 to 15.3 (p = .004), medial cuneiform/5th metatarsal distance improved from 13.3 to 18.5 (p = .004), TN coverage angle improved from 22.4 to 9.7 (p < .001), TN uncoverage % improved from 34.3 to 21.2 (p <.001), TN incongruency angle improved from 39 to 20.1 (p < .001). Deformity correction was well maintained in 14 of 17 patients at final follow up. Union rate of the osteotomy was 100%. Three patients had symptomatic hardware initially, one patient required removal of hardware. One patient developed a superficial infection that cleared. Another patient developed peroneal tendonitis, which resolved with corticosteroid injection. Conclusion: The Z-cut osteotomy is a novel, technically simplified, single incision, single osteotomy alternative to previously described double calcaneus osteotomy techniques for reconstructing flexible moderate to severe adult acquired flatfoot deformity which offers comparable short term clinical and radiographic outcomes with acceptably low complications.
New Persistent Opioid Use Following Common Forefoot Procedures for Treatment of Hallux Valgus
Authors: Finney Fred , Gossett Timothy , Walton David , Talusan Paul , Holmes James 
Published: September 2018

Category: Bunion Introduction/Purpose: Chronic opioid use and abuse is one of the greatest public health challenges in the United States and continues to worsen. Orthopaedic surgeons stand at #4 on the list of top prescribers of opioid analgesics by specialty and are squarely positioned to have an impact on the problem. A recent study revealed an 8% prevalence of new persistent opioid usage following abdominal surgery. At present, the incidence of persistent opioid use after foot and ankle surgery is largely unknown. Operative bunion correction is one of the most commonly performed elective foot and ankle surgeries in this country. We sought to determine the incidence of new persistent opioid use following surgical treatment of hallux valgus and to identify patient factors associated with persistent opioid use. Methods: A nationwide insurance claims data set from January 2010 to June 2015 was used to identify opioid naive patients (defined as patients with no prior opioid use 12 months prior to injury) who underwent surgical treatment of hallux valgus with either a proximal or distal first metatarsal osteotomy. The incidence of new persistent opioid use, defined by opioid prescription fulfillment between 90 and 180 days after surgery was then calculated. Data were assessed for patient factors which may be predictors of new persistent opioid use including surgery type, health insurance type, age, gender, household income, and comorbidities. Results: A total of 38,312 patients underwent surgical treatment of hallux valgus with either a distal or proximal first metatarsal osteotomy and filled a perioperative opioid prescription. The rate of new persistent opioid use among all patients was 5.6%. The majority of patients (90%) underwent treatment with a distal metatarsal osteotomy. Patients who underwent treatment with a proximal metatarsal osteotomy were more likely to have new persistent opioid use (aOR: 1.16; p=0.04). Logistic regression analysis demonstrated that patient factors independently associated with new persistent opioid use included depression, anxiety, alcohol and substance abuse disorders, and certain preoperative pain disorders. Age, gender, and income were not associated with new persistent opioid use. Conclusion: Despite rising national attention, opioid abuse continues to be a growing epidemic. In order for foot and ankle surgeons to help solve this problem, it must first be better defined. New persistent opioid use following surgical treatment of hallux valgus affects a substantial, growing number of patients. Fifty percent of patients using opioids for 3 months will be using them at 5 years. Understanding patient factors associated with persistent opioid use can help clinicians identify and counsel at-risk patients and ultimately focus strategies and interventions aimed at mitigating and eliminating this massive public health problem.
Periprosthetic Ankle Fractures
Authors: Lazarides Alexander , Vovos Tyler , DeOrio James , Easley Mark , Nunley James , Adams Samuel 
Published: September 2018

Category: Ankle Introduction/Purpose: Total ankle replacements (TAR) are an increasingly popular option for the management of tibiotalar arthritis. Periprosthetic fracture is an uncommon but challenging complication of patients undergoing arthroplasty. Evidence on the management of and outcomes from periprosthetic fractures about a TAR are limited. The purpose of this study was to evaluate patients with postoperative periprosthetic fractures about a TAR and determine clinical outcomes of these patients following operative fixation. Additionally, we propose an algorithm for the management of these patients. Methods: We retrospectively analyzed 400 patients who underwent TAR from 2007 through 2017. Charts were reviewed and patients with postoperative fractures were selected for inclusion. Patients with a fracture >4 weeks from index surgery were considered candidates for inclusion. Patients with intraoperative fractures were excluded. Univariate analyses were used to identify differences in outcomes. Results: 32 patients were identified with a postoperative periprosthetic fracture about a TAR. Average age was 65.3 years. Average time to fracture was 39.5 months while average follow up from fracture was 26 months. Fractures were primarily located about the medial malleolus (60.6%). 76.8% of fractures were deemed to be stable (Table 1); 75% of these fractures were managed with ORIF or IMN, while 21% of these fractures were treated with immobilization. 80% of patients with stable fractures treated with immobilization ultimately required surgical intervention. 24.2% of fractures were deemed to be unstable. Fractures about the talus were always unstable and always required revision TAR surgery (100%, p= 0.0002). Conclusion: This retrospective review demonstrates that the majority of periprosthetic fractures about a TAR involve the medial malleolus. Additionally, the majority of stable fractures about a TAR required operative fixation. Despite attempts at nonoperative management, management with immobilization is fraught with a high rate of subsequent surgical intervention. Fractures about the talus should be treated with revision TAR surgery or arthrodesis. Based on these findings, we propose an algorithm for the management of patients with a periprosthetic fracture about a TAR.
Outcome of Autologous Bone Grafting with Preservation of Articular Cartilage to Treat Osteochondral Lesions of the Talus with Large Subchondral Cysts
Authors: Sawa Mikiya , Nakasa Tomoyuki , Yoshikawa Masahiro , Tsuyuguchi Yusuke , Kanemitsu Munekazu , Ota Yuki , Adachi Nobuo 
Published: September 2018

Category: Ankle Introduction/Purpose: Treatment options for osteochondral lesion of the talus (OLT) have substantially increased over the last decade. There are a wide variety of surgical treatments for OLT, and good clinical results have been reported. However, treatment for OLT with large subchondral bone cysts remains under discussion. The combination of autologous bone grafting for subchondral bone cyst with fixation of articular cartilage would be the desirable procedure for the repair of the large subchondral cyst preserving the original cartilage with native structure and geometry. The purpose of this study is to evaluate the clinical outcome of autologous cancellous bone graft and fixation of cartilage fragment for OLT with large subchondral cysts. Methods: Patients comprised seven men and five women, aged 14–70 (mean 35.9) years. All OLTs included full-thickness articular cartilage, extended through subchondral bone and were associated with subchondral cysts. The mean size of the cysts was 9 ×8.6 ×12.3 mm on preoperative CT. Medial lesions were exposed through an oblique medial malleolar osteotomy; lateral lesions through expansion of an anterolateral arthroscopic portal. After refreshed the subchondral cyst, it was grafted with autologous cancellous bone from the distal tibial metaphysis, then cartilage fragments were fixed with nylon suture to surrounding cartilage. Postoperative MRI and CT scans were acquired for all patients at one year after surgery. Seven patients requested screw removal although none had symptoms. The screws were removed and simultaneous arthroscopic examination was performed at 1.5–2 years after surgery with the patients’ permission. The cartilage repair was assessed according to the criteria of the International Cartilage Repair Society (ICRS). Results: Functional outcome was evaluated at 25.3 (15–50) months after surgery. Mean American Orthopedic Foot and Ankle Society ankle-hindfoot outcome score improved from 65.7 to 92 (90–100) postoperatively, with 100% patient satisfaction. All follow-up CT scans showed that the grafts were well consolidated with the surrounding subchondral bone. On MRI one year after surgery, no scans showed any signs of osteochondral graft instability. The mean ICRS arthroscopic score from follow-up arthroscopy was 11.1 (8–12) points, and represented nearly normal cartilage. Conclusion: Our study demonstrated good results of autologous bone grafting in preserving articular cartilage in cases of symptomatic OLT with subchondral cysts. In seven cases, we performed follow-up arthroscopy at 1.5–2 years after primary operation and the chondral fragment showed a smooth surface and good stability. The technique of autologous bone grafting with chondral fragment fixation could be a promising option for treatment of OLT with subchondral cysts.
Subtalar Joint Arthritis After Total Ankle Replacement
Authors: Sokolowski Marc , Zwicky Lukas , Schweizer Christine , Hintermann Beat 
Published: September 2018

Category: Ankle Arthritis Introduction/Purpose: It has been shown that total ankle replacement (TAR) is effective in reducing pain and maintaining function in posttraumatic ankle osteoarthritis (OA). Compared to ankle fusion, TAR restores hindfoot kinematics more physiological. However, the assumption that the maintenance of ankle motion has a protective effect on the subtalar joint is still a matter of debate. Only a scarce number of long-term studies exist to support this statement.The purpose of this study was (1) to evaluate to which extent the integrity of the subtalar joint can be preserved by treating patients with a TAR, (2) to determine the rate of subtalar fusion following TAR, and (3) to determine whether the need of subsequent subtalar fusion was predictable at time of TAR. Methods: A consecutive series of 1140 primary TAR (508 female, 632 male, median age 63.5 years), performed between May 2000 and December 2015, were prospectively documented. The indication for TAR was posttraumatic OA in 78%, primary and systemic OA in 10% each, and other secondary OA in 3% of the cases. 199 subtalar joints were either fused before (n=73) or during TAR surgery (n=126), leaving 941 subtalar joints available for analysis. Radiographs before implantation and at latest follow-up were classified using the Kellgren and Lawrence Grading Score (KLS). In case of a subtalar fusion, the radiograph prior to the fusion was classified. Results: After a median radiographic follow-up of 6.1 years, the KLS remained unchanged in 66% of all cases. While it was increased by one stage in 30%, it was increased by two stages in 3%; whereas, signs of OA decreased by one stage in 1%. Cases with an increase of two stages on the KLS had a longer follow-up compared to cases without increase (p=0.047).37 cases (3.9%) underwent a subtalar joint fusion, of which the indication was progressive OA in 19 cases (51%), instability in 10 cases (27%) and others in 8 cases (22%). Subtalar joints that required a fusion after TAR did not show higher preoperative KLS than the group which did not need a subtalar joint fusion. Conclusion: Apparently, TAR protects the subtalar joint from secondary degeneration, as found in 67% with no increase in KLS. Although 33% showed an increase in the KLS, only 2% required a subtalar fusion due to progressive OA. Overall, the rate of subtalar joint fusion after TAR was low and comparable to the rates reported in the literature. Subtalar joints requiring fusion after TAR did not show higher preoperative rates of OA. Therefore, the KLS classification of subtalar OA on conventional radiographs provides only limited information about the need for postoperative subtalar fusion, and thus need to be interpreted with caution.
The Role of 3D Reconstruction True Volume Analysis in Osteochondral Lesions of the Talus
Authors: Walley Kempland , Gonzalez Tyler , Roush Evan , Saloky Kaitlin , Callahan Ryan , Ludwick Leanne , Juliano Paul , Lewis Gregory , Aynardi Michael 
Published: September 2018

Category: Other Introduction/Purpose: Evaluation and management of osteochondral lesions of the talus (OLTs) often warrant advanced imaging studies such as CT and/or MRI. While MRI has its advantages in determining the degree of cartilage damage, stability of the fragment and edema, CT imaging is better delineates the osseous anatomy and extent of the lesion. The latter imaging modality offers increasing acuity and resolution in characterizing the complex osteochondral landscape via three-dimensional (3D) reconstructions. It is possible that orthopedic surgeons may overestimate the size and misinterpret the morphology of OLT from conventional MRI and CT thereby influencing treatment strategies. The purpose of this study is to determine the utility of a novel means to estimate the true-volume of OLTs using 3D reconstructed images and volume analysis. Methods: After IRB approval, an institutional radiology database was queried for patients with OLTs and compatible CT scans between 2011 and 2016. Fourteen patients were found to have OLT compatible with the software used to approximate true-volumes of 3D reconstructed images. 3D reconstructions were created using Mimics software (Materialise, Belgium). From the 14 reconstructed OLTs, 5 were randomly selected for evaluation. 10 orthopedic surgeons independently estimated the volume of these 5 OLTs via standard CT scans. Then 3D reconstructions were made and true-volume (TV) analysis measurements of each OLT were generated. The percent change in volumes from CT were compared to TVs determined from 3D reconstructive analysis. Results: On average the volume calculated by conventional CT scanner grossly overestimated the actual size of the OLTs. The volume calculated on conventional CT scanner overestimated the size of OLTs compared to the 3D TV reconstructed analysis by 285-864%. Conclusion: Our results show that conventional measurements of OLTS with CT grossly overestimates the size of the lesion by up to 8-times the actual lesion size. This overestimation of volumes of the lesion can drastically change surgical planning and may lead to unnecessary costs associated with specific surgical treatments. With the use of our newly defined model for volume measurement in OLTs, we can more accurately predict the exact size of the OLT. This can better guide surgeons to choices both the correct cartilage restoring procedure as well as the need for bone grafting.