bluuebunny/crossref_metadata_2025_split huggingface dataset:
Outcomes of Exogen low-intensity pulsed ultrasound in the management of delayed union following elective foot and ankle surgery
Authors: Scrimshire Ashley , Torres Paulo , Koziara Michal , Allport Jack 
Published: September 2018

Category: Basic Sciences/Biologics Introduction/Purpose: Exogen low-intensity pulsed ultrasound therapy is well established in the management of fracture delayed or non-union. Its use in trauma has recently been recommended by the National Institute for Clinical Excellence in England. In comparison the use of Exogen for managing delayed union following elective foot and ankle surgery has not previously been reported in the literature. We aim to review the indications for and outcomes following Exogen therapy for managing delayed union following elective foot and ankle surgery in our English tertiary referral centre. Methods: Case notes and imaging were reviewed for all patients receiving Exogen therapy following elective foot and ankle surgery from July 2012 - July 2017 in our centre. Data were collected on patient demographics, smoking status, comorbidities, indications for and type of surgery performed, duration of Exogen therapy and final outcomes. Union was confirmed radiologically and clinically. Results: 58 patients were included, 18 smokers and 8 diabetic. The mean age was 55 years. 50 underwent an arthrodesis, 8 an osteotomy. Exogen was started a mean of 244-days post-operatively. 24 patients went on to complete union; a further 7 were showing good progress towards union. When grouped together the union rate was 53.4% (n=31). Complete union took a mean of 177-days (range 44–441). The non-union rate was 46.6% (n=27) despite a mean of 330-days treatment (range 72–1112). 1 was complicated by infection. There were no significant differences in age, time to commencing Exogen, number of smokers or diabetics between the groups. The non-union group had significantly longer treatment (p=0.003). Union was more likely following an osteotomy (n=6/8,75%) or surgery to the hindfoot (n=6/7,86%). Conclusion: We have found Exogen can be beneficial in managing delayed union following elective foot and ankle surgery for over half of patients. This can potentially reduce the number of revision surgeries required. We found no correlation between patient age, smoking or diabetes in outcome. Union was more likely following a corrective osteotomy or surgery to the hindfoot. This data can help inform clinicians in their decision-making and in counselling patients.
Postoperative infection in foot & ankle surgery
Authors: Shah Ashish , Huntley Samuel , Abyar Eildar , Lehtonen Eva , Naranje Sameer , Anderson Matthew , Kalra Rishi , Hsu Alan , Dahlgren Nicholas 
Published: September 2018

Category: Other Introduction/Purpose: Surgical site infections (SSI) are infections of the incision site, organ, or space at or near the surgical incision within 30 days of the procedure or within 90 days for prosthetic implants. Being the most common nosocomial infection, SSI’s are a burden to the healthcare system as they increase costs, duration of stay, antimicrobial resistance, morbidity, and mortality. While there is limited evidence in the orthopaedic literature suggesting that the incidence of SSI increases during the summer months, this association has not been examined in the setting of foot and ankle surgery. The purpose of this study was to determine whether seasonal variation plays a role in developing SSI’s after orthopaedic foot and ankle surgery. Methods: Data from the National Surgical Quality Improvement Program (NSQIP) years 2011-2015 were used in this study. The pooled and individual incidences of superficial incisional SSI, deep SSI, and organ space SSI were calculated and stratified by quarter of admission. The quarters of admission represent the various seasons (1=winter, 2=spring, 3=summer, 4=fall). Differences in the incidence of SSI as well as various demographic, comorbidity, and complication variables were evaluated using ANOVA for continuous variables and Pearson’s Chi-Square for categorical variables. Results: A total of 17,939 patients were identified. After pooling the superficial, deep, and organ space infections, the overall SSI rate was highest in the summer months (July-September, 3rd quarter) at 2.68% as compared to 2.20%, 2.33%, and 2.14% in the other respective quarters (p=0.338). There was a total of 218 cases of superficial incisional SSI. The summer months had the highest incidence of superficial SSI at 1.38% compared to 1.14%, 1.13%, and 1.21% for 1st, 2nd, and 4th quarters, respectively (p=0.677). There were 145 cases of deep incisional SSI. The third quarter again had the highest rate at 1.02% compared to 0.72%, 0.93%, and 0.60% for 1st, 2nd, and 4th quarter respectively (p=0.105). Conclusion: Our results show that superficial incisional SSI, deep incisional SSI, and open wound infections have increased likelihood during the summer months in the setting of orthopaedic foot and ankle surgery. Some studies have associated the increased temperature and humidity during the summer months with increased rates of infections and our results show similar trends. Additional evidence with larger sample sizes is needed to determine which specific procedures are at highest risk of infection during the summer months.
Innovative ‘Push Screw’ as reduction aid for minimally invasive fixation of calcaneus fracture
Authors: Shah Rajiv 
Published: September 2018

Category: Trauma Introduction/Purpose: Percutaneous reduction of depressed and rotated articular fragments is the most challenging job during minimally invasive fixation of fracture calcaneus. A solid, fully threaded, flat ended, 6.5 mm cancellous ‘Push Screw’ designed by us, serves as novel innovative tool for this purpose. ‘Push Screw’, by its pushing ability; not only reduces the articular fragment but also carries with it a big chunk of underlying subchondral cancellous bone for fixation of subarticular raft screws. We present a study of 28 cases of calcaneus fractures treated with minimally invasive techniques where ‘Push Screws’ were utilized to gain articular reduction of subtalar as well as calcaneocuboid joint. Methods: Twenty eight intra-articular calcaneus fracture cases where ‘Push Screw’ assisted reduction was done were included in present study. Image assisted method of achieving reduction with ‘Push Screws’ comprised of placement of a subarticular guide wire, drilling and tapping of a pilot hole, driving of a flat ended ‘Push Screw’ followed by placement of a subchondral raft screw in reduced articular fragment. ‘Push Screws’ were either replaced or retained. Sequential tightening and strategic placement of two ‘Push Screws’ helped to correct rotation as well as depression. Cases were segregated as per the joints where ‘Push Screws’ were utilized. Results: ‘Push Screw’ assisted subtalar joint restoration was carried out in all 28 cases, while 3 cases required restoration of both; calcaneocuboid as well as subtalar joint. Use of more than one ‘Push Screw’ was required in 8 cases, out of which 3 Sander type III cases required use of three ‘Push Screws’. All these cases had involvement of both subtalar as well as calcaneocuboid joint. In 26 out of 28 cases ‘Push Screws’ were replaced with fully threaded 6.5 mm cancellous screws while in remaining 2 cases they were retained. Malreduction was noticed in 3 cases and loss of initial reduction was noticed in 2 cases. Conclusion: ‘Push Screw’ is a novel innovative tool to achieve articular reduction at minimally invasive reduction of calcaneus fracture. It not only helps to soundly reduce articular facet but also carries with it lifted chunk of subchondral bone for sound fixation of subarticular raft screw. Ease of image aided analysis of reduction, maintenance of reduction and fixation of articular fragment are the unique advantages of ‘Push Screws’. ‘Push Screw’, a cheap and versatile reduction tool also obviates the need for trained assistant.
Management of Hepple Stage V Osteochondral Lesion of the Talus with a Platelet-Rich Plasma Scaffold
Authors: Shi Zhongmin 
Published: September 2018

Category: Ankle Introduction/Purpose: There has been no consensus on the treatment or prognosis of Hepple stage V osteochondral lesions of the talus (OLTs), especially for lesions greater than 1.5 cm2 in size. The objective of this study was to investigate the clinical outcomes achieved upon application of a platelet-rich plasma (PRP) scaffold with a cancellous bone autograft for Hepple stage V OLTs. Methods: Fourteen patients (mean age, 39 years) were treated with a cancellous bone graft and a PRP scaffold between 2013 and 2015. The mean time to surgical treatment was 23.5 months. Ankle X-ray and magnetic resonance imaging were performed at the final follow-up. Functional outcomes were evaluated according to the Visual Analog Scale (VAS) score, American Orthopaedic Foot and Ankle Society (AOFAS) score, and Short Form36 (SF-36) score.The range of motion (ROM) of the ankle joint and complications also were recorded. Results: Thirteen patients completed the full follow-up, with a mean follow-up duration of 18 months. MRI demonstrated the complete regeneration of subchondral bone and cartilage in all patients.The postoperative VAS, AOFAS ankle and hindfoot, and SF-36 scores were improved significantly (all 𝑃 < 0.001) without obvious complications. Conclusion: We suggest that, for the Hepple stage V OLTs, management with cancellous bone graft and PRP scaffold may be a safe and effective treatment.
Combined Anterior and Dual Posterolateral Approaches for Ankle Arthroscopy for Posterior and Anterior Ankle Impingement Syndrome
Authors: Song Bin , Zhou Yunfeng 
Published: September 2018

Category: Arthroscopy Introduction/Purpose: We introduce a novel method of combining the standard anteromedial and anterolateral approaches and dual posterolateral approaches in the arthroscopic treatment of posterior and anterior ankle impingement syndrome and compare the postoperative outcomes with conventional anteromedial/anterolateral and posteromedial/posterolateral Methods: From January 2015 to January 2017, we treated 28 patients with posterior and anterior ankle impingement syndrome by arthroscopy. The patients were divided into the conventional group (n = 13) and the modified group (n = 15) according to the surgical approaches used in the operation. Preoperative and postoperative American Orthopaedic Foot & Ankle Society (AOFAS) score, visual analog scale (VAS) score, range of ankle motion, and operation time were recorded. The average follow-up was 16 months (range 6-24 months). Results: Posterior and anterior ankle impingement syndrome was confirmed arthroscopically in all patients. After the operation, the range of ankle motion in all patients was restored. There was no significant difference in postoperative AOFAS score, VAS score, dorsiflexion, and plantarflexion between the conventional group and the modified group. Moreover, the operation time was significantly reduced in the modified group compared with the conventional group. There was no recurrence of osteophyte and no complications such as infection, neurovascular injury, or delayed healing of surgical incision in the modified group. Conclusion: Dual posterolateral approaches combined with standard anteromedial and anterolateral approaches was a novel method for arthroscopic treatment of posterior and anterior ankle impingement syndrome. It proved to be safe and effective, and significantly reduced the operation time. Reposition, repeated prep and drape, and limb distraction were avoided.
Minimally invasive calcaneal osteotomy
Authors: Teoh Kar , Hariharan Kartik 
Published: September 2018

Category: Hindfoot Introduction/Purpose: A calcaneal osteotomy can be used to treat a variety of pathologic entities in which the hindfoot needs realignment. Minimally invasive calcaneal osteotomy (MICO) is becoming increasingly popular due to being soft tissue friendly, its ability to place other incisions nearby and high union rate. Previous studies have look specifically at medialising MICO or comparing open calcaneal osteotomy versus MICO. The purpose of our study was to compare 3 different types of commonly used MICO in our centre. Methods: Sixty-two MICO which fit the criteria were included in this study. They were performed in our unit from 2010 and 2016 and all patients had at least one year follow up data. The type of osteotomies was as follows: Medialising, n = 34, Lateralising, n =15 and Zadek (Dorsal closing wedge), n =13. Clinical and radiographic data were recorded. The diagnosis for 31/34 of the medialising MICO was Stage 2 PTTD, the diagnosis for 12/15 of the lateralising MICO was cavus foot, while the diagnosis for all Zadek MICO was for insertional Achilles tendinopathy. Apart from the Zadek MICO, the other MICO were all associated with other procedures. The average age (years) were as follows: Medialising, 58 (30 – 74); Lateralising, 33 (14 – 67) and Zadek, 47 (42-62). Results: The average calcaneal displacement was 10.2 (range: 8 – 12) mm for medialising MICO, and 6.6 (4 – 8) mm for lateralising MICO(p=0.021). Average time to union was 7.8 (5.4 – 11.6) weeks for medialising MICO, 6.2 (4.6 to 7.9) weeks for lateralising MICO, and 6.1 (4.1 – 7.6) weeks for Zadek MICO. All the MICO healed radiologically and clinically. Five (8%) patients (Medialising, n = 2; Lateralising n =2; Zadek, n =1) reported transient sural nerve paraesthesia following surgery. Wound problems developed in 5 patients (Lateralising, n =3; Zadek, n =2). The number of total complications were as follow: Medialising, n = 5, Lateralising, n = 7 and Zadek, n =5. Average length of stay was as follows: Medialising, 2(0-8) days; Lateralising, 1(0-3) day and Zadek, 1(0-3) day. Conclusion: Minimally invasive calcaneal osteotomy was safe with a high union rate and low complication rates and length of stay across all 3 common osteotomies. The average calcaneal displacement was significantly less for lateralising than medialising which is similar to reported figures for open osteotomy. Wound problems were more likely for lateralising and Zadek MICO compared to medialising and this could be because of how the osteotomies are shifted.
Computer Foot
Authors: Griend Robert Vander 
Published: September 2018

Category: Midfoot/Forefoot Introduction/Purpose: Metatarsalgia can result from both intrinsic and extrinsic causes of increased plantar pressure. The index patient in this study was a college professor with bilateral metarsalgia (and failed Morton’s neuroma surgeries). In clinic he was noted to be sitting with both feet positioned under his chair (Figure shows example of this position). He indicated that he sat in this position while using his computer for several hours at a time. He was counseled to sit with his feet flat and subsequently noted much improvement in his symptoms. Other patients were then noted to have metatarsalgia and similar computer use foot positions prompting this evaluation of forefoot plantar pressures in this sitting position. Methods: Fifteen patients (eight with computer foot and seven without) were seated in a chair that they could adjust to their normal sitting position. The patients wore socks of their choice but not shoes to avoid loading differences resulting from different types foot wear. A plexiglass plate portable pressure sensor was placed ln the floor. The pressure and contact area was measured for each foot with the foot flat and then the foot positioned with the foot directly under the edge of the chair. Results: The plantar pressures in the seated foot flat position ranged from 8-18 kg (some correlation with leg size/weight and self selected chair height). This pressure was fairly evenly distributed across the entire plantar foot. There were no right-left foot differences. The plantar pressures in the computer foot position (foot directly under the edge of the chair) increased by 40-60% while the contact area decreased by 50% or more. Positioning the foot as far under the chair as possible increased the pressures by an additional 10+%. Conclusion: Foot position while seated can result in increased loads on the plantar forefoot. Maintaining this position for long periods of time-as when working on a computer-can contribute to metatarsalgia . While rarely the only cause of metatarsalgia we have found that about 1/4 of patients with forefoot symptoms do acknowledge that they sit for periods of time in the computer foot position. Change in foot position commonly improves their foot symptoms
Patient Perceptions of Achilles Tendon Rupture
Authors: Vosseller J. Turner , Greisberg Justin 
Published: September 2018

Category: Sports Introduction/Purpose: The optimal treatment of Achilles tendon ruptures (ATRs) is a subject of some debate amongst orthopaedic surgeons. However, patient perceptions of ATRs are unclear. Many patients understanding of Achilles injuries is limited and may be more informed by popular culture than anything objective. Many patients may assume that an ATR necessitates surgical treatment or that surgical treatment is “better” because that is how professional athletes are often treated. These ideas may be related to a patient’s health literacy. We sought to assess patient perceptions of ATRs using a proprietary questionnaire and correlate that with health literacy and the education level of the patient. Methods: Patients presenting to an academic orthopaedic foot and ankle clinic with a complaint of Achilles tendon injury were asked to fill out a demographic form, the LiMP (Literacy in Musculoskeletal Problems) survey to assess musculoskeletal health literacy, and a 22 question survey on ATRs designed to assess patients knowledge and perception of ATRs that was modelled after a similar survey done for meniscal injuries. Results: Twenty-nine patients were surveyed with a mean age of 45 years. 62% of respondents noted that they had little knowledge of the Achilles, with the remaining 38% saying that their knowledge of the Achilles was moderate to considerable. 14% of those surveyed were employed in healthcare. The mean LiMP score was 4.91 (out of 9, mean in general population in another study was 4.68). 70% of patients replied that surgery alone or in combination with physical therapy was the most appropriate treatment for an ATR. Only 11% of patients responded that physical therapy with some immobilization was sufficient. Conclusion: Patient perception of ATR treatment appears to be biased to some degree towards surgery. In an educated patient group that scored well in terms of health literacy, a majority of patients felt that surgical treatment was most appropriate. In a setting in which the optimal treatment has not been fully worked out by surgeons, it is difficult to tell what influence patient perceptions may have on treatment, although it is possible these patient perceptions may cause surgeons to be more surgically aggressive.
Safety and Effectiveness of Talus Subchondroplasty® and Bone Marrow Aspirate Concentrate for Treatment of Osteochondral Defects of the Talus
Authors: Vulcano Ettore , Chan Jimmy 
Published: September 2018

Category: Arthroscopy Introduction/Purpose: Subchondroplasty® is a relatively new technique used to treat multiple conditions associated with bone marrow edema. Asymptomatic talus osteochondral defects (OCD) typically present with no bone marrow edema on MRI. Therefore the aim of this retrospective study is to assess the safety and effectiveness of an arthroscopic-percutaneous procedure for the treatment of painful OCDs using subchondral highly porous injectable calcium phosphate – to address the marrow edema - and intra-articular bone marrow aspirate concentrate (BMAC) – to address joint inflammation. Methods: From September 2016 to November 2016 9 consecutive patients with an isolated symptomatic osteochondral defect were included in the study. The Foot and Ankle Orthopaedic Score (FAOS) and the visual analogue scale (VAS) for pain were administered preoperatively and at the 1 year postoperative mark. At 52 weeks patients were asked if they would have the procedure again. The procedure was performed by debriding only unstable cartilage and joint synovitic tissue. No microfracture was performed to prevent spilling of calcium paste into the joint. At the end of the procedure 8 cc of BMAC were injected into the joint. Patients were allowed to weight bear as tolerated in a sneaker postoperatively. Return to sports was also indicated as tolerated. Results: Mean OCD size as measured on preoperative MRI was 1.3 x 1.4 cm (range, 1 x 0.8 cm to 2 x 2.3 cm). Mean 1.7 cc (range, 1.5 to 2 cc) of calcium paste were injected in the subchondral bone at the level of the OCD, under arthroscopic visualization to debride any calcium paste leakage. All outcome measures demonstrated marked improvement from baseline to final follow-up: The mean weight bearing VAS pain score improved from mean 7.8 (range 6 to 9) to 0.5 (range, 0 to 1); the mean total FAOS improved from mean 67.1 (range, 55 to 79) to mean 90.6 (range, 87 to 95). At the 1-year postoperative visit all patients declared that they would have the procedure again. Conclusion: Despite the short follow up and the limited number of patients, subchondroplasty and BMAC injection offered good pain relief in all patients. The procedure is not technically challenging, it allows for immediate postoperative weight bearing, and does not compromise future treatments in case of recurrence of symptoms. Further high-quality studies are needed to confirm these results and to assess the long-term outcomes of the procedure.
A new arthroscopic BrostrÖm procedure for chronic lateral ankle instability
Authors: Xu Hailin 
Published: September 2018

Category: Arthroscopy Introduction/Purpose: Chronic lateral ankle instability is usually progressed from previous lateral ankle sprain which is not treated properly. Although patients with acute lateral ankle ligament injury are often managed successfully with conservative treatment, approximately 20%-40% will go on developing symptomatic chronic recurrent lateral ankle instability. Several procedures have been introduced to address these patients including open or arthroscopic techniques, the most common of which is the BrostrÖm procedure. The aim of this study was to describe a new outside-in arthroscopic BrostrÖm procedure and its results for treating patients with chronic lateral ankle instability. Methods: Of the 32 patients that were treated, 18 males and 14 females, and aged from 15~57 years (mean 27.8 years). All patients were symptomatic with a combination of recurrent ankle sprains, giving way and avoidance of sports, as well as presented positive anterior drawer test in the physical examination. The history of all patients was over 6 months and conservative treatments were not enough to relieve the symptoms. Standard anteromedial and anterolateral portal was established. Using a suture anchor (2.9 mm Lupine BR, preloaded with double orthocord sutures, DePuy Synthes) and a cannulated needle as a suture passer, anterior talofibular ligament repair was achieved with an outside-in technique. Follow-up was 6~14 months (mean 8.7). Results: Subjective instability and mechanical instability were all significantly improved. No recurrences of ankle instability were reported. The mean AOFAS Ankle-Hindfoot score increased from 74 preoperatively to 95 at final follow-up. 2 patients reported superficial peroneal nerve (SPN) irritation symptom postoperatively but only 1 persisted. 2 patients complained mild pain anteroinferior to the lateral ankle. Conclusion: The arthroscopic outside-in BrostrÖm procedure with a single suture anchor was a safe, effective and reproducible technique for chronic lateral ankle instability. The ankle stability resumed with high clinical success rate. The main complication of this procedure was injury to SPN, which crossed the area of repair. The transient neurologic symptom may be related to stretch injury when establishing the anterolateral portal, while the persistent one may be due to nerve entrapment.