bluuebunny/crossref_metadata_2025_split huggingface dataset:
Validated Risk Stratification System for Prediction of Adverse Events Following Open Reduction and Internal Fixation of the Ankle
Authors: Bohl Daniel , Holmes George , Hamid Kamran , Lin Johnny , Lee Simon 
Published: September 2018

Category: Ankle Introduction/Purpose: As orthopaedic surgery moves towards bundled payments, there is growing interest in identifying patients at high risk for postoperative adverse events. The purpose of this study is to develop and validate a risk stratification system for the occurrence of adverse events following open reduction and internal fixation (ORIF) of the ankle. Methods: Patients undergoing ORIF of closed ankle fractures as part of the National Surgical Quality Improvement Program (NSQIP) were identified. For patients undergoing surgery during 2006-2014, multivariate Cox proportional hazards modeling was used to identify factors that were independently associated with the occurrence of adverse events (including events such as surgical site infection, myocardial infarction, and pulmonary embolism). Based on these results, a nomogram was used to generate a point-scoring system for risk stratification. To evaluate the validity of the point-scoring system, the system was applied to patients undergoing ankle ORIF during 2015-2016. Results: Of the 6,140 patients undergoing surgery during 2006-2014, 5.8% developed an adverse event. Based on the Cox proportional hazards regression, patients were assigned points for each of the following statistically significant risk factors: anemia (+2 points), insulin-dependent diabetes (+2 points), age=65 (+1 point), dependent functional status (+1 point), chronic obstructive pulmonary disease (COPD; +1 point), and hypertension (+1 point; Figure 1A). 4,702 patients were identified in the 2015-2016 validation cohort. Among these patients, the risk-stratification system was found to strongly predict the risk for adverse events (p<0.001, Figure 1B). Conclusion: The occurrence of adverse events following ankle ORIF is associated with anemia, insulin-dependent diabetes, age=65, dependent functional status, COPD, and hypertension. We present and validate a simple point-scoring risk stratification system to predict the risk of adverse events. Future systems of bundled payments for ankle ORIF should exclude high-risk patients from the bundling systems, or make appropriate adjustments in reimbursement based on risk.
Outcomes following treatment of the infected Achilles tendon
Authors: Bowers Mark , Turner Norman , Ryssman Daniel 
Published: September 2018

Category: Sports Introduction/Purpose: Infection following Achilles tendon surgery is a devastating complication and can be difficult to treat. Our purpose was to evaluate clinical and functional outcomes of patients who have undergone treatment for an infected Achilles tendon. Methods: We retrospectively reviewed the medical records of 20 patients who had undergone surgical treatment for an infected Achilles tendon between 2000 and 2016. The mean follow-up time was 21 months (range 2-68 months). All patients underwent extensive debridement of the tendon with removal of all infected tissue and foreign material. Soft tissue wound coverage was utilized for large wounds that were not amenable to primary or secondary closure. All patients received culture specific intravenous antibiotics for three to six weeks. Postoperatively, the extremity was immobilized in a splint followed by a cast until the wound was healed. The cast was then replaced with a walking boot and the patients were provided a physical therapy program. Functional outcomes were measured using the Foot and Ankle Ability Measure (FAAM) Activity of Daily Living (ADL) scale. Results: All wounds had healed at the time of last follow-up. Three patients (15%) required an unplanned return to the operating room for repeat debridement. All patients were able to walk without the use of a gait aid. Five patients (25%) required continued use of a boot or brace during ambulation. The average FAAM score was 87 (range, 71.4-100). At last follow-up, most patients reported their overall function as “normal” or “nearly normal”. Conclusion: Eradication of infection and satisfactory functional results can be attained after radical debridement, wound closure, and administration of culture specific IV antibiotics.
Screw Distraction Technique For Gaining Fibular Length
Authors: Briceno Jorge , Vaughn Joshua , Ye Michael , Kwon John 
Published: September 2018

Category: Trauma Introduction/Purpose: A shortened fibula may be caused by several conditions like tumors, premature closure of the growth plate and most frequently, malunion. Biomechanically a shortened fibula causes a lateral shift of the talus, widening of the ankle mortise, decreased tibiotalar contact area and eventually could lead to osteoarthritis. Even in a posttraumatic scenario, with moderate or severe osteoarthritis, fibular lengthening has shown to be beneficial in terms of pain reduction and improved function.Several osteotomies have been described with their advantages and disadvantages in terms of technical difficulty, need for bone graft and the ability to correct length and rotation.We present an easy and reproducible surgical technique on a case, that allow restoring length and rotation independently and it does not require complex distractor devices. Methods: Case report: A 34 year old female patient who presented 8 months status post initial open reduction internal fixation (ORIF). She developed a fibular nonunion, broken distal fixation with a shortened fibula and non-anatomic mortise and presented for revision surgery.Surgical technique: The fibula is exposed in standard fashion. A fully-threaded cortical screw is placed across the tibia, distal to the fibula fracture and parallel to the plafond. Next, a second screw is placed into the fibula bicortically from anterior to posterior and approximately 12 mm distal to the tibial screw. A toothed laminar spreader is then placed in-between the screws and distracted resulting in a lengthening of the fibula. A 2 mm Kirschner wire is placed to hold reduction once fibular length is restored and ORIF continues in standard fashion. Results: The technique we present has several advantages. The technique is straightforward, easy to reproduce, and cost effective. Since the anchoring points used for distraction are not both in the fibula, rotation is not implicitly locked in as in the case when both anchoring points are in the fibula, allowing for independent and progressive adjustment of both length and rotation. There is also less risk of proximal migration of the fibular head as no force is applied directly to the proximal fibula. There is also less risk of proximal migration of the fibular head as no force is applied directly to the proximal fibula. Conclusion: Fibular lengthening can achieve improved function, pain relief and decrease the risk of osteoarthritis in selected patients. Several techniques with different degrees of difficulty have been described to treat this condition, but most are not versatile enough in correcting the length and rotation independently. The technique that we present has the advantage of correcting the length and rotation as needed, without requiring complex devices.
Accuracy of a Single Tunnel Technique for Reconstruction of the Interosseous Talocalcaneal Ligament
Authors: Bull Patrick , Weber Jeffrey , So Eric 
Published: September 2018

Category: Ankle Introduction/Purpose: Numerous reconstructive techniques to address subtalar joint instability have been described. Interest has focused on direct anatomic repair of the interosseous talocalcaneal ligament (ITCL) with tendon autograft, which is passed through osseous tunnels of the talus and calcaneus within the native anatomic boundaries of the compromised ITCL. To our knowledge, the technique employed to accurately place a guidewire and create a percutaneously developed tunnel through the anatomical footprint of the ITCL to restore it has not been described. The purpose of this study was to confirm that an osseous tunnel could be positioned within the ligamentous footprints accurately and safely, to define anatomic landmarks that can be used as reference points to reproduce an accurate tunnel, and assess the structures at risk during percutaneous reconstruction. Methods: Ten fresh cadaveric below-knee specimens were utilized. Under fluoroscopy, an anterior cruciate ligament guide was utilized to place a drill tunnel from the plantar lateral aspect of the calcaneus, across the sinus tarsi, and through the dorsal medial talus. The monofilament wire was passed through this tunnel to serve as a simulated model for cortical button fixation within the footprint of the ITCL. The first five specimens (group 1) were dissected; structures at risk and wire distance to the center of the ITCL were recorded. The procedure was then performed on the second set of five specimens (group 2) to assess for improvement in our technique. Results: The mean distances from the wire to the ITCL on the calcaneus and talus were 2.92 mm and 4.04 mm, respectively. Mean distances from the wire to ITCL on the calcaneus in groups 1 and 2 were 4.04 mm and 1.80 mm, respectively (p = .04). Mean distances from the wire to ITCL on the talus in groups 1 and 2 were 6.23 mm and 1.84 mm, respectively (p = .08). Violated structures included the tibialis anterior tendon in one specimen, and the most dorsal aspect of the talar head cartilage in 2 specimens. Conclusion: Under fluoroscopic guidance, and with minimal technique experience, a tunnel can be directed across the ITCL footprints accurately and safely. In our last five specimens, we were within 2 mm of the ITCL center, and well within the typical 8.5 mm average ITCL width. In our practice, we have reconstructed the ITCL with a cortical button fixation device using this technique and found it to be efficient and effective.
Deltoid Ligament Repair for Tibiotalar Stabilization and Reduction of Syndesmosis
Authors: Butler Bennet , Hempen Eric , Muriuki Muturi , Havey Robert , Patwardhan Avinash , Kadakia Anish 
Published: September 2018

Category: Ankle Introduction/Purpose: Ankle fractures with combined deltoid ligament/syndesmotic injuries are common. Proper reduction of these injuries may be deceptively difficult due to the complexity of the tibiotalar and syndesmotic articulations. The syndesmosis, in particular, has been shown to have a fairly high rate of malreduction with traditional techniques and intraoperative imaging. Additionally, the deltoid ligament has important contributions to tibiotalar alignment and stability which cannot be replaced with laterally based fixation alone. Deltoid ligament repair has the potential to address both of the proceeding issues, but has fallen out of favor due to a lack of clinical evidence supporting its use. Here we provide cadaveric data showing that deltoid ligament repair can assist with accurate syndesmotic reduction and stabilize the talus in all planes of motion. Methods: 21 lower limbs disarticulated at the knee were obtained for testing. A material testing machine capable of exerting known axial and rotational forces was utilized for testing. A motion capture system was used to accurately track the tibia, talus, and fibula in all planes of translational and rotational movement. The relative positions of each bone with respect to each other were tracked with the ankle hanging under gravitational forces only and with a modest axial force. This was done in intact ankles, ankles following creation of a combined deltoid ligament/syndesmotic injury state, and subsequently after deltoid ligament repair (Figure 1). Results: Compared to the intact state, after injury creation there was a significant increase in talar eversion with respect to the tibia when hanging which corrected with axial loading. Additionally, there was a significant increase in talar internal rotation with respect to the tibia with axial loading. Finally, there was a trend towards increased anterior translation of the fibula with respect to the tibia with axial loading which corrected with hanging. All of these rotational/translational issues were corrected with deltoid ligament repair. Conclusion: This study provides cadaveric evidence that after a combined deltoid ligament/syndesmotic injury, deltoid ligament repair can help ensure accurate syndesmotic reduction and stabilize the tibiotalar joint, especially with respect to inversion/eversion.
Relationship Between Hemoglobin A1c Value and Bone Healing in Diabetic Ankle Fractures Treated Operatively versus Non-operatively
Authors: Hughes Jessica , Hughes Jonathan , Brennan Kindyle , Maldonado Yolanda Munoz , Stahl Daniel 
Published: September 2018

Category: Ankle Introduction/Purpose: Diabetic ankle fractures create unique challenges to fracture management, such as impaired wound / bone healing and increased infection rate. There is inconclusive evidence regarding a specific hemoglobin A1c (A1c) value or glucose level at which the risk of adverse outcomes increases. The aim of this study was to evaluate the A1c level at which the rate of nonunion and other major complications significantly increased in diabetic ankle fractures treated operatively (Op) and non-operatively (Nonop). Methods: This is a retrospective cohort study of diabetic ankle fractures treated Op or NonOp with at least 3 months follow up and a hemoglobin A1c value within 90 days of injury. A query of electronic medical records was performed to identify all patients 18 years of age or older with a diagnosis of diabetes and who underwent Op or NonOp management as the initial treatment of an ankle fracture between January 1, 2004 and December 31, 2014 within a single health system. Union was defined as callus formation at 3 of 4 cortices on radiographs, while nonunion was defined as lack of fracture healing at 6 months based on radiographs of the injured ankle. Multivariable logistic regression analysis was performed to explore demographic, injury-related, and management-related risk factors that influence nonunion and major complications. Results: A total of 243 ankle fractures (130 Op, 113 NonOp) were identified. Nine patients in the NonOp group failed nonoperative management and required surgical fixation. There were 51 patients that developed nonunion/malunions (19 Op, 32 NonOp). Patients with diabetic neuropathy or nephropathy had significantly higher risk of nonunion. In both groups, length of immobilization greater than 12 weeks was a significant predictor of nonunion. There was no A1c level nor preinjury glucose level at which there was significantly increased rate of nonunion or deep infections in either treatment group. However, A1c was a predictor of wound complications at 3 months postoperative in the Op group with an odds ratio of 1.26. There was no significant difference in wound complications at 3 months between treatment groups. Conclusion: While no specific A1c value or glucose level demonstrated a significant rise in fracture nonunion, this study found that diabetic neuropathy and diabetic nephropathy play a significant role in fracture healing. However, hemoglobin A1c was found to be a predictor of wound complications at 3 months postoperative. Additionally, the data suggested a longer duration of immobilization may negatively impact fracture union. These results highlight the complexity of treating diabetic ankle fractures and suggest prolonged immobilization may not be beneficial for this subpopulation.
The Prevalence of Degenerative Changes in Foot of Patients Presenting with Ankle Arthritis
Authors: Johnson-Lynn Sarah , Siddique Malik 
Published: September 2018

Category: Hindfoot Introduction/Purpose: Prevalence of degenerative disease of the joints of the foot is likely to be very low in the general population, as demonstrated by a previous cadaveric study (Muehleman et al. Osteoarthritis and Cartilage, 1997; 5 (1): 23-37). We hypothesised that the prevalence of these changes may be higher in patients presenting with ankle arthritis and we report the prevalence of these additional findings and their effect on patient-reported outcomes (PROMS) at presentation. Methods: 247 patients presented to our unit with ankle arthritis, which later went on to require total ankle replacement and were therefore included in our local joint replacement registry. Of these, 125 had available pre-operative MRI imaging. These images were reviewed by an orthopaedic resident and consultant radiologist. Results: 93 patients had evidence of degenerative change to other joints in the foot. The mean number of other joints affected was 1.25. The most common joints affected were the subtalar (67), talonavicular (32), tarsometatarsal (28), naviculocuneiform (21) and calcaneocuboid (5) joints. 92 patients had completed pre-operative FAOS scores. Multiple ANOVA of this data demonstrated no significant difference between the group with only ankle arthritis and those with other degenerative joints in terms of pre-operative FAOS score (p >0.05). In a subset of 19 patients who had pain diagrams available, most patients did not indicate areas of pain in the regions of their other degenerative joints. Pain drawings suggested 0% TMTJ, 25% TNJ and 78% subtalar joints were symptomatic at presentation. Conclusion: Most patients presenting with ankle arthritis will have at least one additional area of significant degenerative joint disease somewhere in the foot. Many of these will not be overtly symptomatic at the time of presentation and number and location of other degenerative joints in the foot does not result in significant differences in pre-operative PROMS, from those reported in patients with only ankle arthritis.
The circular arc internal fixation for tibio-talo-calcaneal arthrodesis
Authors: Klaue Kaj 
Published: September 2018

Category: Hindfoot Introduction/Purpose: Stabilizing a tibio-talo-calcaneal arthrodesis in anatomical alignment allowing for weight bearing is a technical challenge. Normal anatomy demonstrates alignment of the heel, the posterior subtalar facet, the talus, the ankle joint and the distal tibia on a circular arc. This arc lies on a vertical plane which is slightly angulated inwards in relation to the sagittal plane. Today’s hindfoot nails do not respect this alignment. Complications include malalignment, primary instability, plantar neuropraxia. Purpose of the study is to optimize the technique to stabilize the hindfoot in anatomical alignment. Methods: An instrumentation was designed to create a circular arc bore hole crossing the heel, the posterior subtalar facet, the tibio-talar joint and the distal tibia metaphysis. At the operation, the desired definitive position of the hindfoot is fixed temporarily with Kirschner wires. A guiding frame is fixed to three critical spots of the hindfoot to drill the central hole. Using an image amplifier the hole is bored using a motor driven end cutting flexible reamer which is seated within a rigid curved hull. The nail has the same shape than the hull and is impacted up to the distal tibia. The nail allows for eventual secondary impaction without losing full contact with the surrounding bone. 30 patients have been treated so far using this technique and evaluated more than 6 months post-operatively. Results: The pathology of the operated patients include post-traumatic, congenital and metabolic (diabetes) conditions. The mean follow-up is 16 months. We did observe 3 ruptures of the tibial locking screw which allowed for more spontaneous impaction. All cases went to consolidation without malunion or other complications. One diabetic patient developed a stable pseudarthrosis at the midfoot joints. The patients were treated for 2 weeks post-op with a closed circular cast allowing heel contact to the floor. After 2 weeks our patients did practise partial to full weight bearing using a cam walker for other 6 weeks. Conclusion: The tibio-talo-calcaneal arthrodesis can be successfully treated using a central circular arc shaped nail allowing for full form fit between implant and bone. The anatomical bony alignment of the hindfoot is corrected or preserved. Due to the safe and limited approaches, the technique prevents complications such as neurological complications and non-unions. We expect a shorter period of time between surgical fixation and full weight bearing.
Role of MRI in the Diagnosis of Injury to the Lisfranc Ligament Complex
Authors: Kreulen Christopher , Giza Eric , Escobedo Eva , Bateni Cyrus , Doherty Michael 
Published: September 2018

Category: Sports Introduction/Purpose: Subtle Lisfranc ligamentous injuries are difficult to diagnose and magnetic resonance is becoming a useful tool. The purpose of this study is to evaluate the efficacy of magnetic resonance (MR) imaging for the diagnosis of injuries of the Lisfranc ligament complex. Methods: The radiology database was searched between Jan 1, 2010 and Mar 10, 2015 to identify patients over the age of 18 years who had MR imaging of the foot for suspected injury of the Lisfranc ligament complex. MR images were reviewed by 2 fellowship trained musculoskeletal radiologists, whom were blinded to the original radiology reports. Findings were categorized as: no injury or injury present. Injury was deemed to be present if 2 of the 3 components of C1-M2 ligament showed disruption or signal alterations on T1 and T2 weighted images. Disagreements were resolved by consensus. Correlation was made with surgical findings whenever performed. In patients not undergoing surgery, the presence or absence of injury was determined by clinical examination performed by an orthopedic surgeon and follow-up. Sensitivity, specificity, positive predictive value(PPV), and negative predictive value (NPV) of MR for diagnosis of Lisfranc ligament complex injury was determined. Results: Of 60 patients, 9 were excluded due to a lack of follow-up. Lisfranc injury was determined to be present on MR in 26 patients and 18 underwent surgery. Injury was confirmed in 16, and 2 were intact. 2 patients underwent closed reduction and were clinically determined to be injured. 6 of the injured 26 patients were sprained and not injured/torn on clinical evaluation. Of the 25 patients determined to have no injury on MR, 24 were intact clinically. 1 patient had a Lisfranc injury on follow-up. Sensitivity, specificity, PPV and NPV of MR for detection of significant Lisfranc injury were 94.7% (CI: 73.9% to 99.9%), 75% (CI: 56.6% to 88.5%), 69.2% (CI: 55% to 80.5%) and 96% (CI: 77.9% to 99.4%) respectively. Conclusion: MR has a high sensitivity and negative predictive value for diagnosis of injury to the Lisfranc ligament complex. MR of the foot should be considered in patients with clinical suspicion of injury to the Lisfranc ligament complex, and it is highly accurate in excluding such injuries.