bluuebunny/crossref_metadata_2025_split huggingface dataset:
The etiology of the end-stage varus type ankle arthritis evaluated by weight-bearing simulated computed tomography
Authors: Kurokawa Hiroaki , Taniguchi Akira , Tanaka Yasuhito 
Published: September 2018

Category: Ankle Arthritis Introduction/Purpose: In the patients with the varus type ankle arthritis, the stage of disease was classified according to the narrowing of tibiotalar joint using the weight-bearing ankle radiography. By the Takakura-Tanaka classification, the stage 4 ankle arthritis indicates more than half of the joint space was disappeared in the tibiotalar joint. Inclination of the surface of tibiotalar joint in the patients with stage 4 ranges from neutral to severely varus, that may confuse the etiology of staged ankle arthritis. The purpose of this study was clarifying the etiology of the stage 4 ankle arthritis combined with evaluating the syndesmotic instability using the weight-bearing simulated computed tomography(CT). Methods: Forty nine ankles with stage 4 varus type ankle arthritis were investigated. A weight-bearing simulated CT scan was taken in the neutral position of the ankle with a 300 N pressure from plantar side. In the axial view of the CT at 1 cm proximal to the tibial plafond, the distance between the fibula and the tibia was measured as the fibular clear space (FCS-CT). In the anteroposterior view of the weight-bearing radiography of the ankle, the angle between the tibial shaft and the joint surface of the distal end of the tibia was measured as the tibial anterior surface angle(TAS-Xp). The Pearson correlation coefficient was obtained to identify the correlations between the FCS-CT and the TAS-Xp. P values <0.05 were considered statistically significant. Results: The FCS-CT was 4.3±1.2 mm. The TAS-Xp was 81±4.9°. According to the Pearson correlation coefficient between the FCS-CT and the TAS-Xp, positive correlations were identified (r=0.45; p=0.0011). Conclusion: This study revealed the correlation between the inclination of the distal joint surface of the tibia and distance of the tibiofibular syndesmosis. In the patients with larger FCS-CT, syndesmotic instability may exist, that may lead to the distributed share stress in the tibiotalar joint without the inclination of the joint surface. In the patients with smaller FCS-CT, the varus stress directly transfer to the ankle joint, that may cause to the varus inclination of the distal joint surface of the tibia.
The Effect of Achilles Tendon Loading on Ankle Joint Contact Area and Peak Pressure
Authors: Latt L. Daniel , Ayala Alfonso , Kim Samuel , Lopez Jesus 
Published: September 2018

Category: Ankle Introduction/Purpose: Increased tibiotalar peak pressure (PP) and decreased contact area (CA) following ankle fracture are associated with the development of post-traumatic osteoarthtritis. Lateral talar translation of just 1 mm has been shown to decrease CA by 42%. The impact of talar malalignment in other directions on ankle joint contact pressures (AJCP) are not well understood. The majority of research on AJCP has utilized cadaveric models in which body weight is simulated with an axial load applied through the tibia. This model does not account for Achilles tendon - which transmits the largest tendon force in the body during weight bearing. This study aimed to determine the effects of Achilles tendon loading on tibiotalar CA and PP in an axially loaded cadaver model at different ankle flexion angles. Methods: Ten fresh frozen cadaveric lower extremity specimens transected mid-tibia were dissected free of soft tissues surrounding the ankle, sparing the ligaments. The proximal tibia and fibula were potted in quick drying cement for rigid mounting on a MTS machine. A pressure sensing element (TekScan KScan model 5033) was inserted into the tibiotalar joint and used to measure CA (cm2) and PP (MPa). An axial load of 686 N was applied through the tibia and fibula, followed by a 350 N load via the Achilles tendon to simulate mid-stance conditions. Measurements were taken at neutral position, 15 degrees of dorsiflexion and 15 degrees of plantarflexion, with and without Achilles load. The effects of Achilles load and ankle flexion angle on CA and PP were analyzed using a 2x3 ANOVA. Bonferroni post-hoc adjustments were used for multiple comparisons. Level of statistical significance was set at p < 0.05. Results: ANOVA revealed significant main effects of ankle flexion on contact area and peak pressures (Table 1). Contact area was significantly lower for 15 degrees of plantarflexion than neutral and 15 degrees of dorsiflexion (p < 0.001). In addition, peak pressure was significantly higher for 15 degrees of plantarflexion than neutral and 15 degrees of dorsiflexion. ANOVA also indicated that contact area and peak pressure were significantly higher with Achilles load than without (p < 0.001). No interaction effects were found. Conclusion: The applied Achilles tendon load significantly altered tibiotalar PP in an axially loaded cadaver model. On the other hand, changes in CA with Achilles load were found to be minimal (~1.8%). We also found that the greatest PP and smallest CA occured during plantar flexion. This observation can be explained by a difference in width between the anterior and posterior talus. While the results of this study demonstrate the importance of Achilles tendon load on tibiotalar measurements, further studies investigating the effects of additional factors such as loading techniques are warranted to improve the physiological accuracy of cadaver models.
Open syndesmotic repair for open-book type syndesmotic injury
Authors: Lee Young Koo , Yoo Jungwoo 
Published: September 2018

Category: Trauma Introduction/Purpose: Although there are several approaches to the treatment of syndesmosis injury, there is no gold standard technique. Syndesmotic screw fixation is one of commonly used treatment options but there remains debate topics such as implant breakage and the need for device removal. The purpose of this study was to evaluate the clinical, radiologic and arthroscopic outcomes of open syndesmotic repair for open-book type syndesmotic injury as a new treatment option. Methods: We reviewed the clinical, radiographic and arthroscopic results of 20 patients with traumatic injuries to the distal tibiofibular syndesmosis who were treated with open syndesmotic repair. Arthroscopic evaluations including cotton test were performed at the primary and second-look operation. The American Orthopaedic Foot & Ankle Society (AOFAS) ankle–hindfoot score and visual analog scale (VAS) score were used to evaluate clinical outcomes. The measurement of the tibiofibular clear space and tibiofibular overlap were used to evaluate radiologic outcomes. Both Clinical and radiologic outcome evaluations were performed preoperatively, at 6 weeks and 6 months postoperatively, and at a final follow-up at a minimum 12 months postoperatively. The average follow-up period was 15.3 months. Results: The average AOFAS score improved from 45.4 (range 30-68) preoperatively to 94.12 (range 83-100) at the last follow-up (P < .001). The radiologic parameters of the syndesmosis returned to normal range since the first postoperative follow-up. At second-look arthroscopy, all the patients showed negative cotton test results and the gap of distal tibiofibular joint was remained less than 2 mm in all patients. Conclusion: We had excellent clinical, radiologic and arthroscopic results and there is no major complication. Open syndesmotic repair for open-book type syndesmotic injury is effective in healing and maintaining the injured joint. Therefore this procedure could be a reasonable alternative treatment for traumatic syndesmosis injury of the ankle.
The Plantar Support of the Navicular-Cunieform Joint
Authors: Mason Lyndon , Swanton Eric , Fisher Lauren , Fisher Andrew , Molloy Andrew 
Published: September 2018

Category: Midfoot/Forefoot Introduction/Purpose: Weight-bearing radiographic analysis of pes planus deformities shows, with varying degree of severity, a break in Meary’s line, uncovering of the talar head and an increase in talar-first metatarsal angle. Work by Alsousou (BOFAS 2016) has shown the break in Meary’s line to occur not only at the talonavicular joint (2/3rds of cases) but also at the navicular-cuneiform joint (1/3 rd of cases), distal to the spring ligament and reported posterior tibial tendon insertion. There are currently no anatomical studies analysing the medial longitudinal arch distal to the spring ligament insertion. We aimed to examine this area and assess the anatomy supporting the distal medial longitudinal arch. Methods: We examined 11 cadaveric lower limbs that had been preserved for dissection at the Human Anatomy and Resource Centre at Liverpool University, in a solution of formaldehyde. The lower limbs were carefully dissected to identify the plantar aspect of the medial longitudinal arch Results: In all specimens, the posterior tibial tendon inserted into the plantar medial aspect of the navicular with separate slips to the intermediate and lateral cuneiform. Following insertion, on the navicular, a tendon-like structure extended from this navicular insertion point to the medial cuneiform. This tendon-like structure is statically inserted between the navicular and medial cuneiform allowing the pull of tibialis posterior to act on the navicular and medial cuneiform in tandem. The average width of this ligament (15.2 mm) is much greater than that of the tibialis posterior tendon (9.5 mm). A separate smaller plantar ligament is also present between the navicular and medial cuneiform. Conclusion: The posterior tibialis tendon inserts into the navicular, and what is likely an anthropological remnant, extends onto the medial cuneiform as the navicular cuneiform ligament. This provides a static restraint between two bony insertions and increases the lever arm of the posterior tibial tendon. The major support of the distal aspect of the medial longitudinal arch (i.e. the navicular-cuneiform joint) is provided by the substantial navicular cuneiform ligament.
Incidence and Risk Factors for Complications of Exposed Kirschner Wires Following Elective Forefoot Surgery
Authors: McKenzie James , Rogero Ryan , McDonald Elizabeth , Nicholson Kristen , Shakked Rachel , Raikin Steven , Khawam Sultan 
Published: September 2018

Category: Midfoot/Forefoot Introduction/Purpose: Kirschner wires (K-wires) are commonly utilized for temporary metatarsal and phalangeal fixation following forefoot corrective osteotomies. K-wires can remain in place for up to 6 weeks postoperatively and are at risk for wound complications. Their exposure to the outside environment and direct osseous communication makes infection an important concern for the clinician. Early removal, prophylactic antibiotics, and re-operation are potential sequelae of infected K-wires and can affect outcomes. The purpose of this study is to evaluate the incidence of complications of exposed K-wires after forefoot surgery and identify patient or perioperative risk factors for these complications. Methods: A single surgeon retrospective chart review of forefoot surgeries over the past 10 years was undertaken. Inclusion criteria were any adult undergoing elective forefoot surgery with the use of exposed K-wires. Incidence of wound complication defined as cellulitis, pin site drainage, or migration/loosening of the pin requiring prophylactic antibiotics or early removal was noted. Patient demographic data such as age, BMI, comorbidities, and smoking status were recorded. Perioperative data such as tourniquet time, type of anesthesia, and perioperative antibiotics was also recorded. Univariate analysis was performed via Mann-Whitney test for continuous variables and Chi square test for categorical variables. Multivariate analysis was performed for statistically significant risk factors. Results: 1,217 Patients (2,018 K-wires) were analyzed. There was a 10% complication rate requiring prophylactic antibiotics or early removal (N=123). 40 patients required early pin removal, 54 patients were given oral antibiotics, and 29 patients required both. Female gender (p<0.001), BMI over 28 (p<0.001), general anesthesia (p=0.025), increased tourniquet time (p=0.003) and history of rheumatoid arthritis (p=0.047) were significantly associated with complications. Both male gender [OR 2.62] and tourniquet time [OR 1.01] remained significant on multivariate regression analysis. There was no increased risk of complications with a history of smoking or diabetes. Conclusion: The K-wire is an important modality for providing temporary immobilization of the smaller bones of the forefoot following deformity correction. Male gender, elevated BMI, history of rheumatoid arthritis, general anesthesia, and longer tourniquet time are associated with increased risk of pin infection requiring early removal and/or antibiotics. Further study is needed to determine whether optimizing inflammatory disease, using efficient perioperative technique, and utilizing local anesthesia may limit the risk of wound complications with K-wires in forefoot surgery.
The Incidence and Clinical Utilization of the Calcific Spur in patients with Insertional Achilles Tendinopathy
Authors: Michelson James , Charlson Mark , Holleran Amanda 
Published: September 2018

Category: Hindfoot Introduction/Purpose: Retrospective review of 38 patients treated by two F&A surgeons from 2009 - 2017 for insertional calcific Achilles tendinopathy to determine the location of the calcific spur. We hypothesize that the spur is most commonly seen affecting the posterior fibers. Our secondary hypothesis was that three-dimensional imaging would allow patients to be identified with less than 50% involvement which would make them eligible for resection without the need for reattachment. Methods: Patients with calcific Achilles tendonitis were identified by ICD-10. Patients were included if they had both calcification identified on xrays and MRI imaging. Patients with prior surgery or trauma to the calcaneus or Achilles were excluded. The axial MRI section with the largest cross section of the calcification was used and a line was drawn sagittally and coronally to divide the tendon into four quadrants to identify laterality and anterior vs posterior involvement. Results: There was no significant difference in anatomic location or laterality of the spur between men and women. Seventy five percent of the patients had a spur that encompassed 50% or less of the insertion site. The predominant configuration was posterior in 89.5%, with half of those being lateral and the rest being central or medial. Eighty percent underwent operative management, with two thirds managed by one surgeon and the remaining by the other surgeon. Conclusion: Three dimensional imaging may guide surgical management in treatment of these conditions by identifying those spurs that are predominantly posterior and can be removed without necessitating the need for formal reattachment. This allows for shorter recovery time for the patient and perhaps improved patient outcomes and satisfaction.
NEMISIS Minimally Invasive Surgical Correction for Midfoot Charcot Arthropathy
Authors: Miller Roslyn 
Published: September 2018

Category: Diabetes Introduction/Purpose: The most common cause of Charcot Neuroarthropathy is diabetes. The incidence of diabetes continues to rise globally, with a significant socio-economic burden to both patient and society. Despite good total contact casting techniques, deformity and subsequent ulceration still occurs in this patient group. This make shoe-fitting challenging and the risk of subsequent ulceration increases. This in-turn increases the patients risk of amputation and mortality at five years. Conservative treatment is often protracted, with multiple clinic visits. The has a significant impact on the patients ability to work and quality of life. Open surgery carries a significant risk of poor wound healing and infection again with risk of ulceration. NEMISIS for mid-foot Charcot provides surgeons with a surgical technique for osteotomy, that protects the soft tissues. Methods: The surgical technique utilises Minimally Invasive Shanon and Wedge burrs to perform a biplanar closing wedge osteotomy to achieve a triplanar correction. This takes the tension off the soft tissues which ensures that there is still good tissue cover, without compromising the blood supply to the skin, therefore in theory reducing the risk of infection. Stabilisation is achieved with screws, beams and bolts, +/-medial column plating. Patients are immobilised in a Bholer walker for a period of 3 months post-op. The short to medium term results (3months to 3 years) are presented. Patients are followed up to asses for re-ulceration at the same site, different site, failure of metalwork, return to surgery. Results: 16 patients were followed-up. 14 were diabetics. 4 patients developed deep-seated infection, which required removal of the metal-work. 2 of these patients did not have recurrence of their deformity and progressed to orthotic foot-wear. 1 patient had recurrence of deformity with wound breakdown and is awaiting further surgery. 1 patient had removal of metalwork from midfoot and subsequently developed hind-foot deformity which was stabilised with a hind-foot fusion nail. 1 patient broke the medial beam and bolts and required revision surgery. 2 patients had recurrence of plantar exostosis which was managed with minimally invasive exostectomy. 1 patient had early stabilisation of mid-foot and had subsequent Charcot of the talus, managed conservatively. The remaining patients have not required revision surgery. There have been not amputations. Conclusion: NEMISIS Minimally Invasive Surgery for Mid-Foot Charcot is a promising surgical technique which may help to reduce infection rates and subsequent amputations. The technique is relatively straightforward to teach, but is currently limited by the size of the burrs. The technique however can be coupled with innovation in biologics to aid the surgeon further in trying to achieve a stable plantigrade foot that does not have recurrence of ulceration and deformity.
The risk factors of subsidence of the talar component in the 3 rd generation TNK ankle
Authors: Morita Shigeki , Taniguchi Akira , Tanaka Yasuhito , Takakura Yoshinori 
Published: September 2018

Category: Ankle Arthritis Introduction/Purpose: One of the major reasons for revision surgeries after total ankle arthroplasty (TAA) was subsidence of the talar component. The purpose of this study was to evaluate mid-term outcomes after total ankle arthroplasty(TAA) using the 3 rd generation TNK ankle and investigate risk factors leading to subsidence of the talar component. Methods: Fifty consecutive patients who received the 3 rd generation TNK prosthesis between October 2007 and December 2014 were investigated in this study. Weight-bearing foot and ankle radiographies were taken and evaluated before and after surgery. At least 1 mm sinking of the talar component was defined as the subsidence. BMI, age at the surgery, complications were investigated as patient specific parameter and talar tilting angle(TTA) and inclination of the articular surface of the distal end of tibia were investigated as preoperative radiographic parameters. Position and angle of replaced implant were also investigated using postoperative radiography. Results: Preoperative TTA had positive correlation (p=0.049, Cox model), and the angle between the talar and the 1st metatarsal axis (Meary angle) had negative correlation with subsidence (p=0.042, Cox model). Conclusion: The larger TTA shows varus deformity of the ankle and indicates the potential instability of the ankle, that leads to frequent incidence of ankle sprain postoperatively. Repeated micro trauma causes the loosening and subsidence of the talar component. The smaller Meary angle shows the cavus deformity, that prevents the favorable load distribution to the navicular and calcaneus, and leads to higher pressure concentration to the implant. The larger TTA and smaller Meary angle were risk factors of subsidence of the talar component in the TAA.
Prevalence of AALTF and relevant associated MR findings in persons with and without sinus tarsi pain
Authors: Park Chul-Hyun 
Published: September 2018

Category: Ankle Introduction/Purpose: Sinus tarsi pain is very common, however, etiology of this condition has not been well understood. The purpose of this study was to evaluate differences of MRI findings between persons with and without sinus tarsi pain and to investigate the relationships of sinus tarsi pain and accessory anterolateral talar facet (AALTF). Methods: We reviewed MR images of 120 ankles with sinus tarsi pain in 115 consecutively registered patients. And age- and sex-matched MR images of 120 ankles without pain were also reviewed. We compared the presence of AALTF, calcaneal cyst (CC), bone marrow edema (BME), sinus tarsi fat obliteration (STFO) at the Gissane angle, and coalition between persons with and without sinus tarsi pain. We also compared Gissane angle, talar infero-lateral surface angle (TILSA), and calcaneal cortical thickness (CCT). Of persons with sinus tarsi pain, we compared these parameters between persons with and without AALTF. Results: AALTF was present in 61 ankles (50.8%) with sinus tarsi pain and 34 ankles (28.3%) without sinus tarsi pain (P<0.001). BME (P=0.001) and STFO (P=0.009) were significantly more frequent in persons with sinus tarsi pain. Presences of CC (P=0.108) and coalition (P=0.605) were not different. The Gissane angle was significantly smaller in persons with sinus tarsi pain than in persons without sinus tarsi pain (P<0.001) and TILSA (P=0.032), and CCT (P<0.001) were significantly larger in persons without sinus tarsi pain (Table 1). Of persons with sinus tarsi pain, BME was significantly more frequent in persons with AALTF and TILSA (P=0.032) and CCT were significantly larger in persons with AALTF (Table 2). Conclusion: The MRI findings of patients with sinus tarsi pain showed higher prevalence of AALTF, BME, and STFO. The AALTF may be associated with the MRI findings of talar and calcaneal BME.