bluuebunny/crossref_metadata_2025_split huggingface dataset:
Morphological Analysis of Tibiofibular Disruption Using CT images in Ankle Fractures with Unstable Syndesmotic Injury
Authors: Bae Su-Young , Lee Jung-Hwan , Shin Woo-Jin 
Published: September 2018

Category: Trauma Introduction/Purpose: We aimed to investigate the diagnostic value of CT scan and the morphologic pattern of distal tibiofibular disruption associated with fracture-type or concomitant avulsion fractures in cases of ankle fracture with unstable syndesmosis requiring surgical fixation. Methods: 104 cases images(preoperative plane radiographs and CT axial images) of ankle fractures needed syndesmotic fixation due to unstable syndesmosis on intraoperative stress test were retrospectively reviewed. We classified ankle fractures by Lauge-Hansen classification and AO-OTA classification. Also, associated tibiofibular avulsion fractures including anterior distal tibiofibular avulsion fractures and posterior malleolar fractures were identified. Classification of posterior malleolar fractures based on Bartonícek-Rammelt classification was conducted. We grouped morphologic patterns of distal tibiofibular disruption which is 10 mm proximal to the plafond on CT axial images. We divided them into no diastasis, symmetric diastasis, anterior open, and posterior open according to the diastasis pattern, and no translation, anterior translation, and posterior translation depending on sagittal translation. Chi-square test/Fisher’s exact test and adjusted residual analysis were used for statistical analysis. Results: On LH classification, SER in 78(75%), PER in 18(17.3%), and PA in 8(7.7%). AITFL avulsions were in 37(35.6%) and PM fractures in 58(55.8%). Diastasis patterns were recorded in 30(28.8%) of no diastasis, 41(39.4%) of symmetric diastasis, 3(2.9%) of anterior open, and 30(28.8%) of posterior open. Depending on sagittal translation, 53(51.0%) of no translation, 44(42.3%) of anterior translation, and 7(6.7%) of posterior translation. Neither diastasis nor sagittal translation was revealed by CT in 17.3% of all. Syndesmotic morphologic pattern was various in SER [no diastasis (35.9%, AR=2.7), posterior open (35.9%, AR=2.7), and anterior translation (48.7%, AR=2.3)] whereas PER had relatively consistent pattern (symmetric diastasis in 88.9%, AR=4.7). Tibiofibular avulsion fractures such as Charput and PM fracture did not create distinct feature of widening. Conclusion: In terms of syndesmotic disruption pattern by CT images, PER fractures tend to show simple symmetric diastasis pattern, but SER fractures have a variety of patterns including normal appearance. Even if associated avulsion fracture do not make certain diastasis feature on static CT images, we still have to be careful not to overlook the syndesmotic instability. Diagnostic value of static imaging such as CT may not be higher than expected if not accompanied with intraoperative dynamic stress test.
Selective Arthrodesis for Treatment of Symptomatic Müller-Weiss Disease
Authors: Cao Le , Miao Xu-dong 
Published: September 2018

Category: Midfoot/Forefoot Introduction/Purpose: Müller-Weiss Disease (MWD) is also known as Müller-Weiss Syndrome, which is reported an uncommon adult navicular osteonecrosis, frequently occurring in middle-aged and old females and characterized by compression and fragmentation of the lateral aspect of the navicular bone and progressive malformation. In this study, we report the results of selective midfoot and hindfoot arthrodesis for treating symptomatic MWD. Methods: From January 2006 to December 2011, 28 patients (31 feet) with MWD were treated with selective arthrodesis with tricortical autologous iliac crest block fixated by screws and plate and retrospectively reviewed. These included 24 females and 4 males, with an average age of 53.1 years (31-65 years), and an average symptoms duration of 8.6 years (1.5-13 years). The disease was staged according to Maceira, which included 3 feet in stage II, 15 feet in stage III, 7 feet in stage IV, and 6 feet in stage V. Pre- and postoperative visual analog scale (VAS) score, American Orthopaedic Foot & Ankle Society (AOFAS), radiologic examination, and patients’ satisfaction rate of the surgery were evaluated at an average of 6.6 years (4-12 years) following surgery. Results: Selective arthrodesis according to various symptoms and CT-scan findings related to MWD, 12 feet had talonavicular arthrodesis, 16 feet had talonavicular-cuneiform arthrodesis, and 3 feet had triple arthrodesis. The follow-up visit showed satisfactory outcomes, solid union was achieved in all cases, with average fusion time was 15.2 weeks (12-26 weeks). VAS score reducing from the preoperative 7.8 (7-9) to postoperative 2.3(0-4), whereas the AOFAS score improved from the preoperative 25.4 (19-42) to the postoperative 80.3 (73-88). The patient’s subjective ratings showed excellent results in 8 feet, good results in 18 feet, and fair outcomes in 5 feet. Conclusion: Selective arthrodesis according to various symptoms and CT-scan findings related to MWD, 12 feet had talonavicular arthrodesis, 16 feet had talonavicular-cuneiform arthrodesis, and 3 feet had triple arthrodesis. The follow-up visit showed satisfactory outcomes, solid union was achieved in all cases, with average fusion time was 15.2 weeks (12-26 weeks). VAS score reducing from the preoperative 7.8 (7-9) to postoperative 2.3(0-4), whereas the AOFAS score improved from the preoperative 25.4 (19-42) to the postoperative 80.3 (73-88). The patient’s subjective ratings showed excellent results in 8 feet, good results in 18 feet, and fair outcomes in 5 feet.
The Midfoot Contributes to Power and Work During Single-limb Heel Rise
Authors: DiLiberto Frank , Nawoczenski Deborah 
Published: September 2018

Category: Midfoot/Forefoot Introduction/Purpose: Single-limb heel rise (HR) is used to evaluate muscle performance and clinical outcomes in people with foot and ankle pathology. While the midfoot contributes 13% of total foot/ankle work to forward propulsion during gait, healthy HR performance remains primarily characterized by ankle function. Similar to its function during gait, the midfoot may also generate power during HR to provide the stability needed for ankle push-off power. Further characterization of HR performance by evaluating midfoot kinetics may advance understanding of foot function in the clinical application of the HR task. The purpose of this study was to examine ankle and midfoot power and work during single-limb HR in healthy adults. Methods: Twelve healthy adults [Mean (SD): Age 31.3 (4.9) years; BMI 25.2 (3.3) Kg/m2; 50% male] performed twenty barefoot single-limb heel rises. Multi-segment kinematic and ground reaction force data were recorded with an electromagnetic motion capture system and force plate. Subject-specific, three segment foot models (tibia, rearfoot, forefoot) were derived. Inverse dynamic calculations were performed to obtain ankle and midfoot peak positive and negative powers (joint torque x segmental velocity), as well as the timing of peak powers (% of the heel rise). Midfoot work (integral of power with respect to time), reflecting energy production, was examined as a percentage of the entire work performed at the ankle and midfoot during HR. Group descriptive data were examined as mean (standard deviation) [95% confidence interval]. Results: Ankle peak positive power was 2.8 (0.8) [2.2 - 3.3] W/Kg and occurred during the ascent phase at 7% HR (Figure 1). Midfoot peak positive power was 0.5 (0.2) [0.3 - 0.6] W/Kg occurring at 6%. Ankle peak negative power was 2.1 (0.6) [1.7 - 2.4] W/Kg and occurred during the descent phase at 84% HR. Midfoot peak negative power was 0.4 (0.2) [0.2 - 0.5] W/Kg occurring at 83%. The proportion of midfoot work to total work performed was 13.5 (5.7) [9.8 - 17.1] %. Conclusion: Study findings advance understanding of foot function by demonstrating the contribution of midfoot power and work during HR in healthy adults. Midfoot peak powers were approximately 18% of ankle powers and occurred at similar times during HR. Further, midfoot energy production appears to be an important aspect of healthy HR performance because approximately 14% of the total foot/ankle work occurs at the midfoot. Since active internal muscle and ligament mechanisms are attributed to midfoot power generation, practitioners should consider midfoot tissue loading and muscle performance when implementing the HR task in clinical practice.
The Effect of Gender on Hallux Valgus Surgery
Authors: Lim Winston Shang Rong , Liow Ming Han Lincoln , Goh Graham , Loh Bryan , Koo Kevin , Rikhraj Inderjeet 
Published: September 2018

Category: Bunion Introduction/Purpose: Men are recognized to possess higher pain thresholds, report less pain and have a greater tolerance for pain. With increasing numbers of males seeking hallux valgus (HV) surgery, there is a paucity of literature comparing health-related quality-of-life (HRQoL) outcomes and satisfaction between males and females undergoing HV surgery. Methods: Prospectively collected registry data of 439 patients who underwent HV surgery at a single institution from 2007-2015 were reviewed. Propensity scores generated using logistic regression was used to match males (n=26) to females (n=52) in a 1:2 ratio. Hallux visual analogue scale (VAS) scores, American Orthopaedic Foot and Ankle Society scores (AOFAS), proportion attaining AOFAS minimal clinically important difference (MCID), Short-form 36 (SF-36), satisfaction and expectation scores were analyzed. Hallux valgus (HVA) and inter-metatarsal (IMA) angles were recorded pre- and postoperatively. Results: Before PSM, there were significant differences in age (49.8±17.4 vs 55.2±11.8, p=0.03) and SF-36 role-physical (37.5±43.7 vs 59.2±42.6, p=0.01)(Table 1). After PSM, there were no significant pre-operative differences in hallux VAS, AOFAS and SF-36 HRQoL scores between groups (Table 1). At two-years, males had significantly lower SF-36 general health scores (68.7±20.6 vs 79.3±17.8, p=0.02) (Table 2). In addition, lower proportion of males reported good/excellent satisfaction (73.1% vs 78.8%) and expectation fulfilment (80.8% vs 94.2%) at two-years (Table 3). Similar proportion of males attained MCID for AOFAS (53.8% vs 46.2%, p=0.63) (Table 4). Males and females presented with similar pre-operative HVA (29.3±8.4 vs 28.2±9.3, p=0.63) and IMA (14.4±3.2 vs 13.9±3.4, p=0.53), with successful correction of HVA (14.7±6.5 vs 12.5±7.8, p=0.25) and IMA (9.4±3.3 vs 8.3±3.1, p=0.17) post-operatively (Table 5). Conclusion: Our findings suggest that males may experience lower expectation fulfilment when compared to females after HV surgery, despite resolution of hallux pain, satisfactory radiological correction and attainment of similar proportion of MCID in AOFAS scores. These findings highlight that males may possess higher expectations towards hallux valgus surgery. Future research should focus on factors affecting expectation fulfilment in males undergoing HV surgery.
Comparison of Non-Union and Complication Rates in Primary versus Revision Tibiotalar Arthrodesis
Authors: Neumann Julie , Weinberg Maxwell , Saltzman Charles , Barg Alexej 
Published: September 2018

Category: Ankle Arthritis Introduction/Purpose: Tibiotalar arthrodesis is generally a successful treatment option for patients with end stage ankle arthritis. However, there is a 9% risk of nonunion in patients undergoing primary tibiotalar arthrodesis. Patients with a nonunion often undergo revision ankle arthrodesis, as it is the most common salvage procedure in this situation. To date, only a few studies have evaluated outcomes in patients with revision ankle arthrodesis. The purpose of this clinical study is to directly compare the rate of union and complications in primary versus revision tibiotalar arthrodesis. The hypothesis of this study was that there would be no difference in rate of union and complications between primary and revision ankle arthrodesis. Methods: This is a retrospective review of 455 consecutive patients that underwent either primary or revision tibiotalar arthrodesis between March 2002 to November 2014. Three-hundred eighty-five patients underwent primary arthrodesis and 70 patients underwent revision arthrodesis. Age, gender, body mass index, smoking, and preoperative radiographic deformity were controlled. The primary outcome measure was union rate of tibiotalar arthrodesis. Secondary outcome measures were time to union, rate of wound complications, rate of return to operating room, and rate of development of post-operative deep vein thrombosis (DVT). Results: Average age of the patients was 56 +/- 15 years (range 18-89). The mean follow-up time was 38.3 +/- 27.4 months (range 12-150.4 months). All patients had a minimum follow-up of 12 months. Unions were assessed on routine post-operative radiographs. If there was a concern for nonunion, patients were further assessed with a computerized tomography scan. The nonunion rate of patients who had primary arthrodesis was 37/385 (9.6%) and revision arthrodesis was 6/70 (8.5%) (p=0.74) (Table 1). Additionally, there was not a significant difference between those who had primary versus revision ankle arthrodesis surgery in rate of wound complication, return to the operating room, and post-operative DVT (Table 2). There were no major complications in this study. Conclusion: This is the largest study to directly compare union rates and complication rates in patients who underwent primary versus revision ankle arthrodesis. In this study, primary versus revision tibiotalar arthrodesis does not affect union rate, time to union, rate of wound complications, rate of return to operating room, and rate of development of post-operative DVT.
Percutaneous surgery for overlapping fifth toe
Authors: Bilbao Facundo , Verbner Jonathan , Parise Ana , Villena Daniel , Araujo Maria Gala Santini , Sotelano Pablo , Carrasco Nelly , Carlucci Sofia , Conti Leonardo , Migues Atilio 
Published: September 2018

Category: Lesser Toes Introduction/Purpose: Overlapping fifth toe is an unusual disease in which the fifth toe is adducted, rotated, and hyperextended. This pathology is often asymptomatic, however pain may occur with footwear. Although there are many surgical techniques available, there is yet no gold standard. While old techniques were aggressive and cosmetically inappropriate, newest techniques involve large surgical incisions and risk of neurovascular damage. Percutaneous surgery is a novel approach which avoids the disadvantages that old and new techniques present. It was originally described by De Prado but no case series have been reported in adults up to date. The aim of this study is to describe a percutaneous corrective technique of the overlapping fifth toe and to evaluate its functional results and patient satisfaction. Methods: We performed a retrospective review of 12 feet in 10 adult patients who were surgically treated between 2008 and 2016. The percutaneous surgical technique consisted in a dorsal capsulotomy and extensor tenotomy followed by an osteotomy of the proximal phalanx (as described by De Prado). We added to his procedure the use of a K-wire to stabilize the osteotomies. In 6 of these feet a percutaneous oblique osteotomy of the fifth metatarsal was also performed. This osteotomy was stabilized using the same K-wire, which was removed 1 month after surgery. All patients were clinically rated prior to surgery and at the final follow-up visit using the AOFAS Score for lesser toes. In addition, patients were asked to provide a subjective qualification of the results (pain/cosmetic) as “excellent”, “good”, “regular” and “poor” and to state if they would recommend the surgical procedure to one of their peers. Results: The average follow up was 48 months (104 - 9). Osteotomy consolidation was completely achieved in all patients. There were no infections or wound complications. Mean preoperative AOFAS score was 38 (20-55) and postoperative score was 84 (62-95). Patient subjective qualification after surgery was: excellent for 7 feet, good for 3 and regular and poor for the remaining 2 feet. Nine of the ten patients stated that they would recommend the procedure. Conclusion: Percutaneous treatment of the overlapping fifth toe is a reproducible surgical technique with good functional results, low postoperative complications and good cosmetic acceptance by the patients.
Prognostic risk factors for complications associated with Tibiotalocalcaneal fusion with a nail
Authors: Callahan Ryan , Aynardi Michael , Walley Kempland , Saloky Kaitlin , Juiano Paul 
Published: September 2018

Category: Ankle Introduction/Purpose: Tibiotalocalcaneal (TTC) fusion with a nail is an effective salvage procedure for several foot and ankle pathologies, but it is associated with a relatively high complication rate and often performed on patients with multiple medical comorbidities. There is a paucity of literature that aids in predicting outcomes for patients undergoing TTC fusion with a nail. Methods: Clinical and radiographic outcomes for 82 patients from 2012-2016 who underwent TTC fusion with intramedullary nailing were retrospectively evaluated. Postoperative complications of nonunion, infection, reoperation, and hardware failure were included for comparison. Patient dependent variables and surgeon dependent variables were evaluated for association with these postoperative complications. Results: The overall complication rate for TTC fusion with a nail was 47/82 (57.3%). Diabetes (p=.049), diabetic neuropathy (p=.031), ASA classification (p=.005), and Charcot neuropathy (p=.003) were associated with nonunion of either the tibiotalar or subtalar joints in 29/82 (35.3%) patients. Diabetic neuropathy was associated with need for reoperation (p=.016) in 21/82 (25.6%) patients. Diabetic neuropathy (p=.022) and HbA1C >7.5 (p=.047) was associated with hardware failure in 13/82 (15.9%) patients. The odds ratio (OR) for diabetic neuropathy was 2.99 (p=0.038) for nonunion in the tibiotalar or subtalar joints, 3.46 (p=0.021) for re-operation, and 4.11 (p=0.035) for hardware failure. High ASA classification had an odds ratio of 3.93 (p=0.006) for nonunion in the tibiotalar or subtalar joints. Conclusion: Patients with diabetic neuropathy, Charcot neuropathy, elevated HbA1C, and higher ASA classification demonstrated a higher complication rate in patients undergoing TTC fusion with a nail.
Treatment trends for acquired hallux valgus among orthopedic surgeons and podiatrists
Authors: Callahan Ryan , Aydogan Umur , Liu Guodong , Ba Djibril 
Published: September 2018

Category: Bunion Introduction/Purpose: Foot and ankle surgery is unique in that both orthopedic surgeons and podiatrists perform many of the same procedures. Very little data exists comparing the two groups for treatment trends and potential complications for acquired hallux valgus deformity. The Truven Health MarketScan® Commercial Claims and Encounters database offers a breadth of information for comparing commercially available health insurance claims. The MarketScan® database was utilized to gain understanding in treatment trends between podiatrists and orthopedic surgeons. Methods: MarketScan® database was used to retrospectively search from 2005-2014 for cases involving a diagnosis of hallux valgus (ICD-9 735.0) that included procedural codes for distal metatarsal osteotomy (CPT 28296), double osteotomy (CPT 28299), and first tarsometatarsal arthrodesis (CPT 28297). The procedures were then divided into the provider groups of podiatry (PO) or orthopedic surgery (OS) to compare the trends in treatment options. Additionally, hospital admission within 3 months, reoperation, and pain medication prescriptions were tracked for the separate groups and for the individual procedures within those groups. Results: From 2005-2014, 206409 patients were identified for comparison. Podiatrists performed 87.5% of hallux valgus corrective procedures with significantly different (p<0.0001) treatment approaches with 78.9% distal metatarsal osteotomy (OS 63.2%), 16.2% double osteotomy (OS 25.3%), and 4.9% first tarsometatarsal arthrodesis (OS 11.5%). Orthopedic surgeons and podiatrists demonstrated similar hospital admission rates 3 months from surgery or reoperation at 1.8% and 1.5% respectively. Amongst all providers, there was significantly more (p<0.001) reoperations and admissions after first tarsometatarsal arthrodesis (2.1%) when compared with distal metatarsal (1.5%) and double (1.6%) osteotomies. 9254 patients were available for prescription drug comparison that demonstrated significantly different prescribing trends with orthopedic surgeons prescribing hydrocodone 2.8% (PO 12.9%), oxycodone 39.4% (PO 10.8%), and tramadol 43.4% (PO 60.0%). Conclusion: A large portion of hallux valgus correction is being performed by podiatrists amongst privately insured patients. Podiatrists were much more likely to perform distal metatarsal osteotomy while orthopedic surgeons were more likely to perform double osteotomies and first tarsometatarsal arthrodesis. Hospital admission within 3 months was similar for the providers. Podiatrists were more likely to prescribe hydrocodone and tramadol while orthopedic surgeons demonstrated greater numbers with oxycodone prescriptions.
Payment drivers in Medicare patients undergoing total ankle arthroplasty
Authors: Cunningham Daniel , Adams Samuel , Easley Mark , Karas Vasili , DeOrio James 
Published: September 2018

Category: Ankle Arthritis Introduction/Purpose: The Comprehensive Care for Joint Replacement model (CJR) provides bundled payments for in-hospital and 90-day post-discharge care of patients undergoing total ankle arthroplasty (TAA). Defining patient factors associated with increased costs during TAA could help refine patient selection strategies and identify modifiable preoperative patient factors that can be addressed prior to the patient entering the bundle. Methods: This study is part of an IRB-approved single-center observational study of patients undergoing TAA from 1/1/2012 to 12/15/2016. Patients were included if they met CJR criteria for inclusion into the bundled payment model and had Medicare as the insurance payer. Costs related to readmissions, diagnosis, and procedures that had been excluded by CJR were also excluded from this financial analysis. All inpatient and outpatient payments beginning at the index procedure through 90 days postoperatively were identified. Patient medical profile including Charlson-Deyo and Elixhauser comorbidity scores, preoperative comorbidities, and perioperative factors were then completed based on institutional data and chart review. Additionally, post-discharge disposition, readmissions, emergency department (ED) utilization, and outpatient plastic surgery consultation were recorded within the 90-day bundled payment period. Results: Out of 199 patients with Medicare payments in the study timeframe, 137 had consented to the study and were analyzed. Baseline and operative characteristics are given in Table 1. Increased length of stay (LOS) at the initial procedure, increased Charlson-Deyo comorbidity score, cerebrovascular disease, and peripheral vascular disease were significantly associated with higher payments. Discharge to skilled nursing facility (skilled nursing facility), admissions, ED visits, and wound complications were significant drivers of payment. Conclusion: Increased Charlson-Deyo score and vascular disease along with increased LOS were associated with increased payments from Medicare. Discharge to SNF, readmission, ED visits, and wound complications considerably increased payments. This study identifies the relationship between patient profile and increased financial burden, highlighting the potential utility of pre-operative mitigation of modifiable risk factors and stratification of payments based on patient profile. Lastly, reducing rates of SNF placement, readmission, ED visitation, and wound complications are targets for decreasing costs for patients undergoing TAA.