bluuebunny/crossref_metadata_2025_split huggingface dataset:
Medial Structure Injury During Suture Button Insertion Utilizing “Center-Center” Technique for Syndesmotic Stabilization
Authors: Reb Christopher , Brandao Roberto , Van Dyke Bryan , Berlet Gregory , Prissel Mark 
Published: September 2018

Category: Ankle Introduction/Purpose: The “Center-Center” technique for syndesmosis fixation has been described as an improved and reliable technique for proper reduction of the syndesmosis during ankle fracture repair. Concurrently, the use of a flexible suture button is becoming an established means of syndesmotic stabilization. The purpose of this cadaveric study was to assess for medial structure injury during the placement of a suture button utilizing the “Center-Center” technique for ankle syndesmotic repair at 3 insertion intervals. Methods: Simulated open syndesmosis repair was performed on 10 cadaveric specimens. Three intervals were measured at 10 mm, 20 mm, and 30 mm proximal to the level of the distal tibial articular surface along the fibula. Proper longitudinal alignment of the “Center-Center” technique was completed under fluoroscopic guidance and was marked on the medial aspect of the tibia. The 3 intervals were drilled in the appropriate technique trajectory. The suture button was passed through each drill-hole interval. Using a digital caliper, the distance was measured from each suture button aperture with respect to the anterior tibial tendon, posterior tibial tendon, greater saphenous vein and nerve by single observer. Results: The average distance from the suture button to each anatomic structure was -2.61 ± 3.75 mm for the greater saphenous vein, -3.44 ± 6.82 mm for the saphenous nerve, 15.09 ± 4.02 mm for the anterior tibial tendon, and -21.70 ± 4.89 mm for the posterior tibial tendon. Direct impingement of the greater saphenous vein was seen in 11/30 (36.6%) interval measurements. Six of the 11 (54.5%) entrapment intervals occurred at the 10 mm drill hole. Conclusion: The results of the present study suggest the use of the “Center-Center” technique for syndesmotic repair with suture button application does involve risk of injury to the greater saphenous vein and saphenous nerve. These injuries could manifest as persistent lower extremity edema and paresthesias for injury to the saphenous vein and nerve respectively. The “Center-Center” technique with suture button fixation may warrant a minimal medial open dissection, prior to quadricortical drilling, for optimal placement to prevent neurovascular injury.
Improved Reduction of the Tibiofibular Syndesmosis with Tightrope Compared to Screw Fixation
Authors: Taylor Michel , Sanders David , Tieszer Christina 
Published: September 2018

Category: Trauma Introduction/Purpose: Flexible fixation of the tibio-fibular syndesmosis is designed to allow increased ankle motion and to potentially improve clinical outcomes compared to screw fixation. Flexible fixation has also been suggested to improve the rate of anatomic reduction. This randomized, multi-center study was designed to compare the rate of malreduction following treatment of high fibular fractures associated with syndesmosis injury with open reduction and internal fixation with either two fully threaded screws or one knotless Tightrope device. Methods: 101 patients from eleven sites were randomized and underwent operative fixation of their AO/OTA 44-C injury between June 2015-16. All patients demonstrated radiographic syndesmosis diastasis or instability following malleolar bony fixation. Open syndesmosis reduction was performed in all cases. Fixation was randomized to either Tightrope (T) or screws (S). Surgical techniques and rehabilitation were standardized. Follow-up at 2 and 6 weeks, 3, 6 and 12 months. The primary outcome measure was the rate of malreduction based on bilateral ankle CT scan results at 3 months post fixation. Secondary outcome measures included adverse events, reoperation, and validated functional outcomes including the EQ5D, OM Score, FADI, and WPAI. The estimated sample size required to detect a difference in reduction rate was 72 patients, but the estimated sample size required to detect a difference in functional outcome scores was 240 patients, suggesting the study was adequately powered for radiographic results only. Results: The rate of malreduction was 39% using screws compared to 15% using Tightrope (p = 0.028). Analysis of CT results was performed using a 2 mm translation or 10 degree rotation threshold for malreduction, and included fibular translation, syndesmosis distance, medial compression; and rotation. Patients in Group T had greater anterior translation compared to the contralateral limb (p=0.007) or Group S (p = 0.04). Group T syndesmoses also had greater diastasis compared to control limb (p=.005) and less fibular medialization compared to Group S (p = 0.05). Functional outcome measures demonstrated significant improvements but no differences between groups. FADI scores at each time interval were equivalent. The reoperation rate was higher in the screw group compared to Tightrope (30% vs 4%, p= 0.02). Conclusion: Treatment of tibio-fibular syndesmosis injury with the knotless flexible Tightrope device achieves lower rates of malreduction and reoperation compared to screw fixation.
Isolated Intermetatarsal Ligament Release as Primary Surgical Management for Morton’s Neuroma
Authors: Abdelaziz Mohamed , Whitelaw Kathryn , Waryasz Gregory , Guss Daniel , Johnson Anne , DiGiovanni Christopher 
Published: September 2018

Category: Midfoot/Forefoot Introduction/Purpose: While the precise pathoetiology of Morton’s neuroma remains unclear, nerve inflammation as a result of chronic entrapment from the overlying intermetatarsal ligament (IML) may play a role. Traditional surgical management involved common digital nerve transection with neuroma excision, but this procedure risks unpredictable formation of a stump neuroma and potential worsening of symptoms. Accordingly, the senior author has over the past six years espoused isolated IML release and common digital nerve decompression in lieu of nerve transection or neuroma excision as an alternative treatment strategy. We hypothesized that IML release offers effective pain relief and high patient satisfaction level as a surgical treatment for recalcitrant Morton’s neuroma without the risk of stump neuroma formation or symptom exacerbation. Methods: Medical records for all consecutive patients treated surgically with isolated single interspace IML release for symptomatic and recalcitrant Morton’s neuroma over a four year period at a large academic medical center were examined. Any adult patient with clinically diagnosed Morton’s neuroma who had failed at least three months of conservative treatment and who then underwent single-webspace IML decompression were included. Any patient who had less than three months postoperative follow up, had undergone revisional neuroma surgery, or had undergone additional procedures at the time of the IML release were excluded. Overall patient satisfaction as well as pre- and post-operative Visual Analog Pain Scale (VAS) assessments were recorded for all patients. Results: Eleven patients underwent isolated, single interspace IML decompression for Morton’s neuroma over this time frame. One of these patients had a neuroma localized to the second web space and 10 were localized to the third web space. Average follow-up was 10.8± 9 (3-32) months (Table 1). VAS pain scores averaged 6.4 ± 1.9 (4-9) preoperatively and decreased to an average of 1.5 ± 1.6 (0-5) at final follow up (P = 0.003). All patients reported significant pain improvement and an overall satisfaction with the procedure (would undergo it again). No patients returned to the operating room, there were no postoperative infection nor worsening of pain, and no other complications were reported. Conclusion: Isolated single interspace IML release of chronically symptomatic Morton’s neuroma shows promising short-term results regarding pain relief and overall patient satisfaction, with few complications and no demonstrated risk of recurrent neuroma formation, permanent numbness, or postoperative symptom exacerbation. The authors’ collective experience with this approach has been positive enough over the past six years to result in the entire abandonment of the practice of neuroma excision in this patient population.
The Influence of Diabetes Mellitus on Ankle Fracture Treatment
Authors: Aiyer Amiethab , Hillam Jeffery , Smyth Niall , Kaplan Jonathan 
Published: September 2018

Category: Trauma Introduction/Purpose: Diabetes mellitus is an epidemic affecting millions of individuals in the United States. This presents a challenging clinical problem from a surgical perspective, because of concerns for postoperative complications, including delayed wound healing, infection or compromise of fixation/repair constructs. The goal of this paper was to retrospectively review outcomes data from the American College of Surgeons: National Surgical Quality Improvement Program (ACS-NSQIP) to delineate more clearly the impact that diabetes has on operative treatment of ankle fractures, including bimalleolar and lateral malleolar injuries. Methods: Patients were identified from the 2006-2015 ACS-NSQIP database. Diabetic and non-diabetic cohorts were evaluated to compare demographics, comorbidities, perioperative details and 30-day outcomes. Univariate analysis was performed using chi-squared or Fisher’s exact and Wilcoxon signed-rank tests. A multivariate logistic regression model was created to identify independent risk factors for complications. Odds ratios were computed at the 95% confidence interval. Results: There were a total of 3745 (bimalleolar injuries [1579], lateral malleolar injuries [2166]) patients identified. With regard to treatment of distal fibular or bimalleolar injuries, diabetic patients were more likely to have a longer length of hospital stay (p < 0.05). Based on multivariate analysis, diabetic patients undergoing operative fixation of bimalleolar injuries are at higher risk for superficial incisional surgical site infection (SSI) (OR 3.26; p=0.01), any complication (OR 1.73; p<0.001), myocardial infarction (OR 10.89; p=0.046), and readmission (OR 2.38; p=0.01). In the setting of lateral malleolar fracture operative fixation, diabetic patients were at higher risk for any complication (OR 2.48; p=0.002), return to OR for unexpected complications (OR 5.88; p<0.001), and urinary tract infection (OR 4.72; p=0.03) Conclusion: Based on upon the results of this study, diabetic patients are at higher risk for postoperative complications after ankle fracture fixation, namely infection and re-operation and readmission to the hospital within 30 days after surgery. This information can help clinicians guide patients appropriately prior to surgery.
The Effect of Depression on Pain Perception and Function in the Foot and Ankle Patient
Authors: Alejandro Shannon , Geswell Matthew , Grandizio Louis , Graham Jove , Cush Gerard 
Published: September 2018

Category: Other Introduction/Purpose: Foot and ankle (FA) pain can be found in up to 20% of the adult population.1 Etiologies are multifactorial and include neurologic injury, trauma, deformity, tendinopathies and psychological factors. The purpose of this investigation is to assess psychological factors contributing to FA pain in surgical and nonsurgical patients. By identifying how psychological factors influence patient reported pain and disability, clinicians may be able to develop interventions to decrease catastrophic thinking and improve psychological well-being prior to considering surgical intervention Methods: All patients seen in a FA clinic by a single fellowship trained orthopaedic surgeon from August 2016 to October 2016 were included. All patients completed 5 functional assessments prior to their visit (PHQ-2, VAS Pain Scale, FAAM, PSEQ, PCS). We divided the patients into two groups based on their performance on the PHQ (PHQ < 3, or PHQ = 3), which measures depression. Scores = 3 are indicative of clinical depression. Nonparametric Wilcoxon testing was used to determine whether the distributions of the other scores (VAS Pain Scale, FAAM, PSEQ and PCS) were significantly different between these two groups. Results: Of the 225 patients included in our analysis, there were 175 (88%) had PHQ-2 depression scores of < 3 (Group 1) and 50 (22%) had scores = 3 (Group 2). Group 2 demonstrated a statistically significant increase in VAS Pain Scale and PCS. In addition, patients in Group 2 showed statistically significant decreases in FAAM and PSEQ. Patients in Group 2 were statistically more likely to be obese, use tobacco, and be unemployed. Conclusion: In patients with common FA complaints, those with clinical depression, as assessed by the PHQ-2, demonstrated increased pain scores, decreased ability to cope with pain, and lower functional outcome scores compared to patients without depression. Tobacco use, obesity and employment status were found to independently affect pain, coping, and function of patients. These data suggest that depression can significantly affect a patient’s ability to cope with pain and to achieve a higher functional outcome. This data suggests patients with depression may have increased difficulty coping with their FA ailment leading to the need for increased counseling regarding expected outcomes.
First Tarsometatarsal Joint Shape and Orientation
Authors: de Cesar Netto Cesar , Staggers Jackson , Smith Walter , Lee Sung , Phillips Sierra , Pinto Martim , Dos Santos Alexandre Godoy , Roberts Lauren , Sahranavard Bahman , Shah Ashish 
Published: September 2018

Category: Bunion Introduction/Purpose: Studies have demonstrated that patients with hallux valgus (HV) deformities have increased mobility in the first tarsometatarsal (TMT) joint. Anatomical factors widely considered to play a role in the instability are shape and frontal plane orientation of the joint. An oblique rather than horizontal orientation of the articular surfaces and a round shape, rather than a flat shape, are believed to predispose to the deformity. The purpose of this study was to assess whether the shape and angulation of the first TMT joint are affected by the positioning of the foot and orientation of the x-ray beam. Methods: Ten adult above knee fresh frozen cadaveric specimens were used, with a mean age of 79.9 (range, 54-88) years. There were no clinical forefoot deformities noted in any of the feet. One of the specimens had moderate ankle arthritis and one had a mild cavus-varus. A radiolucent loading apparatus was built that, allowing neutral positioning of a plantigrade foot and controlled angulation of 5o, 10 o, 15o and 20o in dorsiflexion, plantarflexion, inversion and eversion. Fluoroscopic images were obtained of each cadaveric specimen in all seventeen different positions, with the x-ray beam perpendicular to the floor and aiming to the base of the 1st metatarsal. Two blinded orthopaedic surgeons independently measured the 1st tarsometatarsal (TMT) joint angle and graded the distal articular cartilage of the medial cuneiform as flat or curved. Readers also graded the image quality into assessing the joint into “Low”, “Intermediate” and “Good”. Results: 1st TMT joint angle was 112.92o ± 6.89o. Values were significantly different between cadaveric specimens (p<.0001). There was a tendency for increased valgus angulation of the joint in images positioned in neutral, plantarflexion and inversion and decreased valgus angulation with dorsiflexion and eversion.Regarding the shape of the distal articular cartilage of the medial cuneiform, joints with flat configuration showed significantly increased mean 1st TMT joint angle when compared to curved surfaces (115.9o vs. 110.7o, p<.0001). In 8 out of 10 of the cadaveric specimens (80%) the shape of the 1st TMT joint changed between curved or flat configuration depending on the positioning of the foot. In only 2/10 (20%) the joint configuration remained the same for all different positions (one flat and one curved). Conclusion: Our cadaveric study found that the shape and angulation of the first TMT joint is affected by the positioning of the foot and orientation of the x-ray beam. Clinical usefulness of the 1st TMT radiographic anatomical characteristics is limited and should not influence in the treatment of patients with possible instability the first tarsometatarsal (TMT) joint.
Midfoot power during walking and stair ascent in healthy adults
Authors: DiLiberto Frank , Houck Jeff , Nawoczenski Deborah 
Published: September 2018

Category: Midfoot/Forefoot Introduction/Purpose: Intrinsic foot muscles have the capacity to attenuate and reverse arch deformation under loaded conditions. This function is proposed to be an important component in generating the midfoot power and stability requisite for gastroc-soleus muscle action at the ankle during forward propulsion. Synergistic activation of intrinsic foot muscles is proposed to function as a ‘foot core’ during weightbearing activity that is analogous to the function of the smaller muscles at the spine. If this theory were sound, midfoot power would be expected to increase, potentially in proportion to ankle power, as the muscular demand of a task increases. The purpose of this study was to explore the nature and behavior of midfoot and ankle power during walking and stair ascent in healthy adults. Methods: Twelve healthy adults [Mean (SD): Age 31.3 (4.9) years; BMI 25.2 (3.4) Kg/m2; 50% female] walked, ascended a standard step, and ascended a high step. An electromagnetic sensor motion capture system and force plate were used to record multi-segment foot motion and ground reaction force data. Subject-specific three segment foot models (tibia, rearfoot, forefoot) were derived. Inverse dynamic calculations were performed to obtain ankle and midfoot positive total power. Positive total power, calculated as the sum of positive power (joint torque x segmental velocity) after heel off, reflects the entire amount of ankle or midfoot push-off power generated for a given task. The proportion of midfoot to ankle positive total power was also calculated. Multiple one-way repeated measures ANOVAs were conducted to evaluate differences in power variables across tasks. Bonferroni adjusted pairwise comparisons were made to assess differences in main effects. Effect sizes between conditions were also examined (Cohen’s d). Results: Significant main effects were found for both ankle and midfoot positive total power [ankle F = 29.8 (p < 0.01); midfoot F = 63.1 (p < 0.01)]. Pairwise comparisons revealed that total power significantly increased across each activity at both the ankle (d range: 0.09 - 2.3) and midfoot (d range: 1.4 - 2.9) [all p < 0.05]. Interestingly, a main effect was not observed in the proportion of midfoot to ankle total power across activity [F = 1.2 (p = 0.33)] (Figure 1). Conclusion: The findings of this study provide preliminary support for the idea of a midfoot ‘foot core’ system. While increased ankle and midfoot power is required as the muscular demand of activity increases from walking to standard step and high step ascent, the proportion of midfoot to ankle total power remains the same. Study findings may assist practitioner understanding in addressing regional foot muscle imbalances and advancing patients to higher-level functional activities.
Trampoline Related Injuries
Authors: Doty Jesse , Voskuil Ryan , Swafford Rachel 
Published: September 2018

Category: Trauma Introduction/Purpose: Jump parks (or trampoline parks) have become one of the fastest growing recreational businesses in the United States. With their increasing popularity, notable changes in trampoline related injuries might be evident, particularly involving the lower extremity. There is no published data dedicated to adult trampoline injuries and little information regarding the safety profiles of commercial jump parks. Methods: We conducted a retrospective review including all patients sustaining trampoline related injuries presenting during a two-year period. Data collection included patient demographics and injury characteristics of trampoline injuries in the domestic setting and at commercial jump parks. Results: One hundred fifty patients (34%) sustained injuries at commercial jump parks versus 289 patients (66%) on home trampolines. Fifty-five percent of the jump park injuries were fractures/dislocations, compared to 44% of the home trampoline injuries. Eighteen adults sustained fractures or dislocations at the jump park (45%), while only five adults sustained fractures or dislocations using home trampolines (17%). Seventeen (94%) and 2 (40%) represented adult lower extremity injuries in jump parks and home trampolines respectively. In children, 47 (72%) of the jump park fractures/dislocations were lower extremity, and 41 (33%) of the home trampoline fractures/dislocations were lower extremity. Ten (9%) pediatric and 9 (23%) adult jump park patients required operative intervention, compared to 17 (7%) pediatric and 3 (10%) adult home trampoline patients requiring surgery. Conclusion: Emergency room visits, hospital admissions, and surgical intervention secondary to jump park related injuries are not uncommon in children and adults. There were a higher percentage of total fractures or dislocations, adult fractures, lower extremity fractures, and operative interventions among patients with commercial jump park injuries compared with those who sustained home trampoline injuries.