bluuebunny/crossref_metadata_2025_split huggingface dataset:
The Effect of Three Foot Types on the Achilles Tendon Lever Arm
Authors: Deforth Manja , Zwicky Lukas , Lang Tamara Horn , Hintermann Beat 
Published: September 2018

Category: Hindfoot Introduction/Purpose: During locomotion, propulsion of the body is created by the force of the triceps surae complex as it is transmitted to the metatarsal heads. The amount and pattern of the resulting propulsion force highly depends on the moment arm of the Achilles tendon. To our knowledge, no data exists on how and to which extent position and morphology of the foot affects the moment arm of the Achilles tendon. The aim of this study was 1) to develop a method to determine the Achilles tendon moment arm, and 2) to calculate the Achilles tendon moment arm with the foot in different degrees of dorsi- and plantarflexion for 3 foot types (normal arched foot, pes planus, and pes cavus). Methods: 99 study participants with a healthy ankle joint (males, 40; females, 59; mean age 49 [range, 14 – 78] years) were included. Participants’ foot type was classified as a normal arched foot (n = 33), as pes planus (n = 33), or as pes cavus (n = 33) based on the calcaneal inclination angle (CI) (Figure 1). Besides the foot type, the foot length (FL), the calcaneal insertion of the Achilles tendon (ATI), the angle (a) between the line (L) connecting ATI with the center of rotation of the ankle (COR) and the horizontal line (L’) were measured on the lateral radiographs. The interrater reliabilities of measuring a on radiographs and on MRIs were compared. The lever arm of the Achilles tendon (L’calculated) was calculated as following (foot and tibia were regarded as two rigid segments; the influences of other muscles were neglected): L’calculated = cos(a - plantarflexion)*L Results: The interrater reliability of a was higher on radiographs (ICC = 0.84, [0.73 – 0.91]) than on MRIs (ICC = 0.61, [0.27 – 0.81]). The ICC comparing a measured on MRIs and radiographs was 0.63 [0.50-0.74]. There was no difference in FL between the three foot types (p = 0.199). However, the average a was significantly different (normal arched foot 31°, pes planus 24°, pes cavus 36°, p = 0.021), resulting in a statistically significant shorter Achilles tendon lever arm for pes cavus than for pes planus (p < 0.0001) and normal arched feet (p = 0.006) in neutral position. The maximum lever arm for the three different foot types was reached at different degrees of plantarflexion (Figure 2). Conclusion: The assessment of the Achilles tendon lever arm using radiographs is reliable. The foot configuration determines the lever arm of the Achilles tendon for a given flexion position of the foot. It also determines the plantarflexion position where the Achilles tendon reaches the maximum of its lever arm. This has to be taken into consideration when planning surgeries that change a or L, as they may also result in changes of plantarflexion power.
Outcomes of Surgical Treatment of Talar Osteochondral Lesions using Bone Marrow Aspirate and Microgenized Allograft Cartilage Extra-cellular Matrix
Authors: Dekker Robert , Patel Milap 
Published: September 2018

Category: Sports Introduction/Purpose: Osteochondral lesions (OCL) of the talus are frequently seen after ankle injury and often result in significant morbidity. Apart from a single case report, we are the first to present a case series of OCLs treated with bone marrow aspirate and micronized extracellular allograft cartilage matrix designed to serve as a scaffold to promote autologous healing. Short to mid-term outcomes using this technique are virtually absent in the literature. In this study, we sought to assess pre- and post-procedural functional outcomes using the validated Patient Reported Outcomes Measurement Information System (PROMIS) as well as assess cartilage incorporation on postoperative ankle MRI using the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) scoring. Methods: Twelve patients with symptomatic talar OCLs (14 lesions) were prospectively recruited. Average age was 44 years. Each underwent ankle arthroscopy, ankle arthrotomy, marrow stimulation and lesion repair using BMA and micronized extracellular allograft cartilage matrix by a single fellowship trained foot and ankle Orthopedic Surgeon. Preoperative, 6 month and 1 year postoperative PROMIS pain and function scores were collected prospectively. At six months, all patients underwent ankle MRI scans that were reviewed by a fellowship trained musculoskeletal radiologist for MOCART scoring. Results: No significant difference was detected between mean pre- and postoperative PROMIS function (41.4 vs 38.1; p=.54) and pain (61.3 vs 66.1) scores at 6 months. No significant difference was seen between mean pre- and postoperative PROMIS function (41.4 vs 41.8; p=.93) and pain (61.3 vs 58; p=.48) scores at 1 year. Mean postoperative MOCART score was 53.2 with a range of 5 to 90. Conclusion: Bone marrow aspirate and extracellular allograft cartilage matrix for surgical treatment of talar OCL showed no statistically significant improvement in functional outcomes at 6 months and 1 year. No correlation between functional outcomes and MOCART score was seen.
Comparison of the effects of forefoot jointpreserving arthroplasty and resectionreplacement arthroplasty on walking plantar pressure distribution and patient-based outcomes in patients with rheumatoid arthritis
Authors: Ebina Kosuke , Tsuboi Hideki , Hirao Makoto , Noguchi Takaaki 
Published: September 2018

Category: Midfoot/Forefoot Introduction/Purpose: The purpose of this retrospective study is to clarify the difference in plantar pressure distribution during walking and related patient-based outcomes between forefoot joint-preserving arthroplasty and resection-replacement arthroplasty in patients with rheumatoid arthritis (RA). Methods: Four groups of patients were recruited. Group1 included 22 feet of 11 healthy controls (age 48.6 years), Group2 included 36 feet of 28 RA patients with deformed non-operated feet (age 64.8 years, Disease activity score assessing 28 joints with CRP [DAS28-CRP] 2.3), Group3 included 27 feet of 20 RA patients with metatarsal head resection-replacement arthroplasty (age 60.7 years, post-operative duration 5.6 years, DAS28-CRP 2.4), and Group4 included 34 feet of 29 RA patients with metatarsophalangeal (MTP) joint-preserving arthroplasty (age 64.6 years, post-operative duration 3.2 years, DAS28-CRP 2.3). Patients were cross-sectionally examined by F-SCAN II® to evaluate walking plantar pressure, and the self-administered foot evaluation questionnaire (SAFE-Q). Twenty joint-preserving arthroplasty feet were longitudinally examined at both pre- and post-operation. Results: In the 1st MTP joint, Group4 showed higher pressure distribution (13.7%) than Group2 (8.0%) and Group3 (6.7%) (P<0.001). In the 2nd-3 rd MTP joint, Group4 showed lower pressure distribution (9.0%) than Group2 (14.5%) (P<0.001) and Group3 (11.5%) (P<0.05). On longitudinal analysis, Group4 showed increased 1st MTP joint pressure (8.5% vs. 14.7%; P<0.001) and decreased 2nd-3 rd MTP joint pressure (15.2% vs. 10.7%; P<0.01) distribution. In the SAFE-Q subscale scores, Group4 showed higher scores than Group3 in pain and pain-related scores (84.1 vs. 71.7; P<0.01) and in shoe-related scores (62.5 vs. 43.1; P<0.01). Conclusion: Joint-preserving arthroplasty resulted in higher 1st MTP joint and lower 2nd-3 rd MTP joint pressures than resection-replacement arthroplasty, which were associated with better patient-based outcomes.
Aesthetic Treatment of Tillaux-Chaput fractures
Authors: Feng Shi-Ming 
Published: September 2018

Category: Arthroscopy Introduction/Purpose: This study aim to investigate the clinical result of treating Tillaux-Chaput fractures using the all-inside ankle arthroscopy technique. Methods: We retrospectively evaluated 23 Tillaux-Chaput fractures patients who underwent all-inside ankle arthroscopy technique and were follow-up from May 2013 to June 2016. There were 15 males and 8 females, with the mean age of 30.4 years (range, 10-57 years). Right ankle was involved in 15 patients and left ankle in 8 patients. Eighteen patients had single Tillaux-Chaput fractures and 5 patients had combined proximal fibular fractures. While 20 cases were diagnosed by X-rays and 3 cases by CT. Ankle arthroscopy was used through the anterolateral and anteriormedal approaches for closed reduction and internal fixation using Herbert screw(s). The joints function was performed using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle hindfoot scale score. Results: Operative incisions of 23 cases were primary healing without complications of nerve, vessel and tendon injuries. The period of follow-up was 19.6 months (range, 12-25 months) and the time of Fracture union was 23.3 weeks (range, 12-36 weeks). At the time of last follow-up, none of the patients had any restriction in the ankle function and range of motion, with the ankle pain and weight-bearing walking pain. AOFAS score was changed from preoperative 53.3 points to 92.1 points, with the excellent-good rate of 100%. Conclusion: All-arthroscopy teatment by the anterolateral and anteriormedal approaches is a precise and effective method for closed reduction and internal fixation of Tillaux-Chaput fractures and deserves clinical application.
Compressive Stockings After Hindfoot and Ankle Surgery
Authors: Grubhofer Florian , Wirth Stephan 
Published: September 2018

Category: Hindfoot Introduction/Purpose: Swelling and pain are common after foot and ankle procedures. We hypothesized that compressive stockings (CS) treatment after hindfoot surgery would positively influence patient outcomes. Methods: We undertook this randomized controlled trial in 87 consecutive patients to analyze the clinical effect of CS after hindfoot and ankle surgery and evaluate CS-wearing compliance using sensors that were implanted into CS. Ankle swelling, pain status, quality of life (SF-36 score), and the American Orthopaedic Foot & Ankle Score (AOFAS) were set as the primary end points. The CS wearing time in hours and percentage were investigated as the secondary end points. All participants with CS (group I) were informed about the implanted sensor after the CS were taken off. A subgroup analysis of group I was performed to detect differences between patients with high vs low compliance. Results: At 12 weeks, the results of ankle swelling (mean 234 mm in group I and 232 mm in group II), pain in the visual analog scale (1.7 group I vs 1.9 in group II), the SF-36 score (38 points in group I vs 30 points in group II), and the AOFAS score (a mean of 76 points in both groups) showed no statistical differences between the 2 groups. The mean wearing time was 136 (range, 0-470) hours, which corresponds to a compliance rate of 65%. Sixteen participants had high compliance (>80%, >170 hours), and 21 patients had low or noncompliance. The clinical results of patients with high wearing compliance were not significantly better compared to the results of patients with low compliance. Conclusion: CS therapy after ankle and hindfoot surgery was associated with a low wearing compliance and did not influence ankle swelling, function, pain, and the quality of life compared to the control group. Furthermore, the clinical results of patients with high compliance were not better compared to the results of patients with low or noncompliance wearing behavior.
Tibiotalocalcaneal Arthrodesis Using a Straight Intramedullary Nail
Authors: Jeyaseelan Lucky , Cullen Nicholas , Goldberg Andrew , Welck Matthew 
Published: September 2018

Category: Hindfoot Introduction/Purpose: Tibiotalocalcaneal (TTC) arthrodesis using a hindfoot intramedullary nail has been shown to be a safe and reliable technique in patients with severe ankle and hindfoot disease. There is debate about the use of straight nails versus curved nails. Proponents of the curved nail argue that straight nails predispose to greater risk of lateral plantar nerve injury, poor calcaneal bone purchase and inability to maintain satisfactory hindfoot valgus alignment. However, the subtalar joint is a condyloid joint enabling rotation of the talus on the calcaneum to create varus/valgus position of the calcaneal tuberosity. We present a clinical series of patients undergoing TTC fusion using a straight nail assessed by clinical and radiological outcomes to establish whether theoretical risks of straight nails are reflected in clinical practice. Methods: This single centre, retrospective study of prospectively collected data on a sequential series of patients to undergo TTC fusion, with pre and post-operative weight bearing CT imaging. Data was collected on indication for procedure, co-morbidities, post-operative complications, union rate as well as clinical scores, EQ5D and MOXFQ. Weight bearing CT imaging was analysed using the validated TALUS™ (torque ankle lever arm system) method on weight bearing CT, providing calcaneal offset, hindfoot angle and hindfoot alignment. These were used as markers of hindfoot alignment. Results: 65 patients (37 males, 28 females) were included in the study, with an average age of 57 years. Average follow-up was 20 months. Indications for TTC fusion included Charcot arthropathy, talar avascular necrosis, post traumatic arthritis and non-union of previous arthrodeses. Union rate was 91% (59/65). Overall complication rate was 11% (7/65) and most were minor wound complications. There were no plantar nerve injuries noted. There were no nail cut outs from the calcaneum. On all markers of hindfoot alignment, cases showed a more physiological degree of hindfoot valgus compared to pre-operative measures. There were significant improvement in both EQ5D and MOXFQ scores (p<0.05). Conclusion: We present the largest series of TTC fusion using a straight intramedullary nail and the first series to analyse hindfoot alignment using weight bearing 3D CT imaging. Our data regarding correction of hindfoot alignment is supported by biomechanical theories of subtalar varus/valgus, being related to rotatory changes at the subtalar joint, questioning the perceived need for a curved nail. This is particularly at the level of the entry point of the nail. The principles of valgus hindfoot nails are based on biomechanical laboratory studies and cadaveric studies, neither of which reflect our findings in clinical practice.
Pigmented Villonodular Synovitis of the Foot and Ankle
Authors: Jeyaseelan Lucky , Cullen Nicholas , Welck Matthew , Goldberg Andrew 
Published: September 2018

Category: Other Introduction/Purpose: Pigmented Villonodular Synovitis (PVNS) is a benign but potentially locally aggressive condition, that results in an increased proliferation of synovium, causing villous or nodular changes of synovial-lined joints and tendon sheaths. The estimated incidence of PVNS is 1.8 new cases annually per million people, of which 2.5% occur in the foot and ankle, reflected by the limited reports of PVNS in the foot and ankle literature. We present our clinical experience of 76 patients presenting with PVNS about the foot and ankle. Methods: Patients with PVNS of the foot and ankle were identified from our tertiary referral hospital patient database from 2007 to 2017. The case notes were carefully reviewed to analyse the clinical, radiological, and histopathological features and to investigate their clinical behaviour, management and the factors influencing recurrence. Results: 76 patients were identified (32 male, 44 female) with a mean age of 39 years and mean follow-up of 5 years. The majority of cases were of localised, nodular PVNS (52%, 40/76) with the diffuse PVNS cases (48%, 36/76) presenting most commonly in the hindfoot. The most common presentation was of a swelling/lump (78%- 62/79), of which pain was an associated feature in 11% (7/62) and restricted range of motion a feature in 10% (6/62). Osteoarthritic change and cortical erosions were more commonly associated with diffuse PVNS. All patients underwent open synovectomy with a recurrence rate of 11% (7/76), all of which were the diffuse type. In those cases where synovectomy was paired with arthrodesis of the joint, there were no cases of recurrence (12%,9/76). Conclusion: We present our tertiary referral experience of PVNS in the foot and ankle as the largest series in the foot ankle ankle literature to date. A high index of suspicion is required in diagnosing PVNS. Nodular PVNS appears more common in the foot whereas diffuse PVNS more common in the ankle and hindfoot. Open synovectomy yields low recurrence rates. Although theorised, there is insufficient evidence to establish whether concurrent arthrodesis of the affected joint reduces risk of recurrence.
Expected bony contact
Authors: Kıyak Görkem , Esemenli Tanıl 
Published: September 2018

Category: Bunion Introduction/Purpose: Hallux Valgus has been traditionally quantitated by measuring Hallux Valgus Angle (HVA) and Intermetatarsal Angle (IMA). Classic treatment algorithms based on angular measurements limits the use of distal chevron osteotomy to cases with an IMA less than 15º, assuming possible correction is only 4-6º which is equivalent to 4 – 6 mm displacement. There are studies confirming that larger displacement distal osteotomies can be safely performed. Since distal metatarsal osteotomies provide a correction by shifting, we have created a new algorithm based on the expected bony contact and aim to use the full potential of the distal chevron osteotomy. The purpose of the present study is to investigate if this new concept is more reliable than the widely accepted angular measurements in hallux valgus surgery. Methods: Patients with symptomatic hallux valgus subdivided as mild, moderate and severe hallux valgus using traditional angular radiologic measurements. After excluding the mild cases we calculated the expected bony contact by measuring the width of metatarsal head, and the required amount of lateral shifting. We performed a modified chevron osteotomy with extended plantar limb for the cases if the expected bony contact is more than 20%. We excluded patients with congenital deformities of the foot, hallux rigidus, tarsometatarsal (TMT) instability previous first ray trauma or foot and ankle surgery, diagnosis of rheumatic, dysmetabolic, neurologic, infective or psychiatric pathologies. The 100-point AOFAS hallux-metatarso-phalangeal-interphalangeal scale was used to assess the clinical outcome. We also recorded per and postoperative complications like infection, hallux varus, recurrence, etc. Radiologic measurements recorded for statistical analysis. Results: There were 24 patients suitable for chevron osteotomy according to our classification. We also subdivided our patients as moderate (14) and severe hallux valgus (10) with traditional classification. Table shows the Radiographic results and AOFAS scores by groups Paired t-tests showed significant improvement comparing pre-op and post-op AOFAS scores, IMA, HVA and sesamoid position of moderate, severe and all patient subgroups. (p<0.001) Unpaired t-tests showed that the difference is not significant between moderate and severe subgroups when we compare post-op AOFAS scores, IMA, HVA and sesamoid position. (p>0.05) The difference between the expected bony contacts was not statistically significant in the moderate and severe subgroups. Conclusion: Modified chevron osteotomy performed well enough radiologically and from the perspective of patient satisfaction when used according to the new concept of “expected bony contact” criteria. Dividing patients into angular subgroups did not affect the results of modified chevron osteotomy. The amount of possible lateral translation is not correlated with IMA and HVA. Our study has shown that expected bony contact is a reliable criteria and superior to angular measurements for preoperative planning in hallux valgus surgery.
Risk factors for rerupture after conservative management of acute Achilles tendon rupture
Authors: Lee Kang , Won Jong-Hwa 
Published: September 2018

Category: Sports Introduction/Purpose: Recently, results after conservative management for acute Achilles tendon rupture have been improving after the introduction of real time assessment of tendon healing using ultrasonography and introduction of early weight-bearing and functional brace. Yet, many surgeons prefer surgical management of all acute ruptures due to the risk of tendon rerupture. The purposes of this study are to evaluate incidence and pattern of rerupture of Achilles tendon after complete healing, and to investigate factors related to it. Methods: A total of 202 patients with acute Achilles tendon rupture, who underwent conservative management with cast(3 to 7 weeks) and functional brace, were the subjects of this study. In patients having both tendons injured, only one side was randomly selected for analysis. Hence, for 202 patients, migration free survivorship was analyzed using Kaplan-Meier method, and association with possible risk factors was analyzed by Cox regression analysis using proportional hazards model. Factors include age, sex, history of Achilles tendinopathy, cast duration, calf atrophy(mean calf circumference difference at least 2 cm), possibility of SHR(single heel raise), Achilles thickness after complete healing, and insufficient opposition of tendon ends(10mm>gap>5 mm) after cast, initial gap with ankle neutral. Results: Rerupture occurred in 7 of 202 patients. Factors significantly associated with rerupture in Kaplan-Meier survivorship analysis and univariate Cox regression analysis were sex, history of Achilles tendinopathy, calf atrophy, possibility of SHR. When these factors were analyzed by multivariate analysis, possibility of SHR was the only significant factor with a hazard ratio of 3.14. Conclusion: Our data suggest that possibility of SHR requires special attention during the follow-up. The risk of rerupture after conservative management of acute Achilles tendon rupture can be reduced by sufficient recovery of calf muscle strength with early weightbearing and accelerated rehabilitation with aid of ultrasonography.
Tenogenic differentiation of mesenchymal stem cells
Authors: Lee Seung Yeol , Kim Hyang , Lee Kyoung Min 
Published: September 2018

Category: Basic Sciences/Biologics Introduction/Purpose: Tendon repair has been a challenging issue for surgeons in treating. Although tissue engineering with mesenchymal stem cells (MSC) have been used for tendon repair in both in vivo and in vitro, the stem cells are obtained through invasive procedures, and there is usually a lack of adequate numbers for clinical use. The purpose of this study was to compare the potential of tri-lineage differentiation and to investigate the potential of tenogenic differentiation of human tonsil derived MSCs (T-MSCs), bone marrow derived MSCs (BM-MSCs), and adipose tissue derived MSCs (AD-MSCs). Methods: Each tissue was obtained from 8 patients. After isolation of MSCs, flow cytometry analysis was used to characterize the phenotypes of the MSCs. Differentiation capacity to adipo-, osteo-, and chondrocytes were induced by culturing each MSCs for 3 weeks in commercially available media. Each MSCs was treated with 5ng/ml and 10ng/ml of TGF-ß3 with vehicle control. Results: Immunophenotypic surface marker analysis of BM-MSC, AD-MSC, and TMSCs revealed that these MSCs expressed a typical MSCs. mRNA expression levels of the markers for tri-lineage differentiation were significantly lower in TMSC than other MSCs. The tenogenic transcription factor, scleraxis, showed a statistically significant increase in all MSCs differentiation groups except for the 7th day TMSC differentiation group (Figure). Gene expression of tenascin-C, an ECM glycoprotein, was specifically expressed in the T-MSC differentiation group at 14 days (Figure). Comparing the ratio of collagen 1 to collagen 3 genes, the BM-MSC showed a decrease in the ratio on days 3 and 7 unlike AD-MSCs and TMSCs. Only TMSC showed a significant increase in the ratio compared with other MSCs on the 14th day. Conclusion: The tonsil-MSC has low fat, bone and cartilage differentiation potential and has excellent tendon-specific differentiation potential, thus being highly useful as a tendon-tailored cell therapy agent.