bluuebunny/crossref_metadata_2025_split huggingface dataset:
Reproducible measurements for radiographically assessing longitudinal tarsal axes of severe cavus or flatfoot deformity
Authors: Kido Masamitsu , Ikoma Kazuya , Hosokawa Toshihiro , Imai Kan , Maki Masahiro , Ohashi Suzuyo , Kubo Toshikazu 
Published: September 2018

Category: Other Introduction/Purpose: Calcaneal pitch and Meary’s angles are commonly used to assess longitudinal foot arches on lateral-view radiographs. Several different methods have been described in literatures to obtain the talar, first metatarsal, calcaneal, and plantar axes, but their reliability and reproducibility still remain to be evaluated. The aim of this study was to determine the most reproducible methods for radiographically evaluating the longitudinal axes. Methods: Standing radiographic images of 40 feet from consecutive outpatients, 22 feet with a severe cavus deformity and 48 feet with a severe flatfoot deformity, were obtained to measure the longitudinal axes of the talus, first metatarsal, calcaneus and plantar surface by using six, five, four and three different methods, respectively, that were described in the previous reports (Figure). Interobserver and intraobserver correlation coefficients were calculated by three observers. Results: The best interobserver and intraobserver correlation coefficients were obtained for methods that used a line bisecting the angle formed by the lines tangential to the superior and inferior margins of the talus (Method B), a line connecting the center of the first metatarsal head and the midpoint of the visualized base of the first metatarsal (Method J), and a line drawn tangential to the inferior surface of the calcaneus (Method L). For the plantar axis, the method that used the horizontal plane [reference axis] was considered the best. Conclusion: The above mentioned methods were considered ideal for the radiographic assessment of longitudinal foot arches, even in severely deformed feet. This study could contribute to standardized assessments of foot deformities.
Hallux valgus correction using Scarf-Osteotomy leads to shortening of the first metatarsal
Authors: Lenz Christopher , Borbas Paul 
Published: September 2018

Category: Bunion Introduction/Purpose: In hallux valgus deformity less weight can be borne by the first ray which may lead to transfer metatarsalgia and lesser toe deformities. Depending on the exact configuration of the bone cuts during the scarf procedure, an iatrogenic shortening of the first metatarsal may occur which may diminish weightbearing ability of the first ray as well, causing transfer metatarsalgia. The aim of the present study was therefore to determine preoperative and postoperative changes in length of the first metatarsal by using different methods of measuring metatarsal length. Methods: A consecutive series of 118 feet in 106 patients (89% female, 11% male) was enrolled, who underwent correctional osteotomy (Scarf-with/without Akin-Osteotomy) from May 2015 to July 2017 at a single institution. Patients, who underwent additional shortening osteotomy of the metatarsals, were excluded. Average age at the time of surgery was 51 years (range, 14 to 83 years). Pre- and postoperative angle measurement of hallux valgus- and intermetatarsal angle was assessed at between six weeks and three months postoperatively on standardized weight-bearing radiographs in dorsoplantar plane. We also identified early complications in hallux valgus surgery. An assessment and comparison of different methods of measuring metatarsal length (length of first metatarsal, ratio first to second metatarsal, Coughlin method) postoperatively was performed to identify the amount of shortening with this technique. Results: Hallux valgus angle was statistically significant reduced by an average of 18.6° (28.3° preoperatively to 9.7° postoperatively, p < 0.001), intermetatarsal angle by 7.7° (12.8° to 5.1°, p < 0.001). Measuring the length of the first metatarsal, in all three methods a statistically significant reduction of the first metatarsal length could be detected. Mean absolute shortening of 1.8 mm was measured (p < 0.001). The ratio of the first metatarsal to the second metatarsal averaged -0.03 (p = 0.02). The mean relative lengthening of the second metatarsal, using the method described by Coughlin, was 0.42 mm (from 4.51 to 4.89 mm, p < 0.001) on average. Of those three methods, the Coughlin method showed the highest correlation. 6 minor complications were observed (5%). Conclusion: In the current study we could demonstrate a significant reduction of hallux valgus angle and intermetatarsal angle with hallux valgus correction using Scarf-/Akin-Osteotomy, with a low complication rate. However, statistically significant shortening of the first metatarsal could be detected as well. Further research is required to improve and establish a hallux valgus correction technique without shortening of the first metatarsal.
Does Concurrent Distal Tibiofibular Joint Arthrodesis Affect the Nonunion and Complication Rates of Tibiotalar Arthrodesis?
Authors: Neumann Julie , Weinberg Maxwell , Zhang Chong , Saltzman Charles , Barg Alexej 
Published: September 2018

Category: Ankle 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. To date, it is unclear whether concurrent distal tibio-fibular joint arthrodesis affects this nonunion rate as there have been no studies directly comparing patients with and without arthrodesis of the distal tibio-fibular joint. The purpose of this clinical study is to compare the rate of nonunion in patients with a distal tibio-fibular fusion to those without a distal tibio-fibular fusion in the setting of a primary, open ankle arthrodesis. The hypothesis of this study was that the addition of a distal tibio-fibular fusion would decrease the nonunion rate in patients undergoing open ankle arthrodesis. Methods: This is a retrospective review of 521 consecutive patients from October 2002 to April 2016. 366 ankles from 354 unique patients met inclusion criteria. All patients underwent primary, open tibiotalar arthrodesis. 250 patients underwent open tibiotalar arthrodesis with a distal tibio-fibular fusion and 116 patients underwent open tibiotalar arthrodesis without a distal tibio-fibular fusion. Age, gender, body mass index, smoking, and preoperative radiographic deformity were controlled. The primary outcome measure was nonunion rate of tibiotalar arthrodesis. Secondary outcome measures were time to union, rate of wound complications, and rate of development of post-operative deep vein thrombosis (DVT)/Pulmonary embolism (PE). Results: Average age of the patients was 56.2 +/- 14.2 years. Mean follow-up time was 33.8 months. Unions were assessed on routine post-operative radiographs and by clinical examination. If there was a concern for nonunion, computerized tomography scan was utilized for further assessment. Nonunion rate of patients who had the distal tibio-fibular joint included was 19/250 (8%) and nonunion rate of those who did not have the distal tibio-fibular joint fused was 14/116 (12%) (p=0.16). There was no significant difference between those who had the distal tibio-fibular joint included versus who did not in wound complication rate (27% vs 31%, p=0.40), time to union (4.9 weeks versus 5 weeks, p =0.54), and DVT/PE rate (5% vs 3%, p=0.41), respectively [Table 1]. There were no major complications. Conclusion: To our knowledge, this is the first study directly comparing nonunion rates and complication rates in patients who underwent primary, open ankle arthrodesis with and without distal tibio-fibular joint arthrodesis. In this study, inclusion of the distal tibio-fibular joint in tibiotalar arthrodesis does not affect nonunion rate in patients undergoing primary, open ankle arthrodesis. Additionally, inclusion of the distal tibio-fibular joint does not affect rate of wound complication, time to union, and DVT/PE rate.
Do Pain, Functional Disability, and Gait in End-stage Ankle Arthritis Worsen with Associated Varus Coronal Plane Deformity?
Authors: Ramaskandhan Jayasree , Allport Jack , Siddique Malik 
Published: September 2018

Category: Ankle Arthritis Introduction/Purpose: There is paucity of literature on quantitative gait changes in patients with increased coronal plane deformity along with end stage ankle arthritis. We aimed to study the difference in spatial temporal parameters of gait and patient reported functional measure in patients with end stage arthritis and no coronal plane deformity vs. varus deformity of >10? Methods: All patients diagnosed with end stage arthritis between April 2016 and December 2017 underwent an objective gait assessment using Tekscan system (BioSense Medicals, UK) as part of routine clinical practice. Of this cohort, patients with bilateral ankle arthritis, previous reconstructive surgery, inflammatory arthritis, hip and knee arthritis, spinal pathology and underlying neurological conditions were excluded. Patients with unilateral ankle arthritis for a diagnosis of osteoarthritis or post traumatic arthritis were included in this study. These patients were grouped into Group A (no coronal plane deformity) vs. Group B (varus deformity of more than 10?). In these patients differences were studied between the groups for temporal spatial parameters of gait and functional disability levels measured by MOX-FQ scores. Statistical tests included normality tests, student t’tests, chi square evaluation and analysis of variance tests with SPSS. Results: Of 33 patients, 22 were in Group A (N=22) and 10 in Group B (N=10). There was no difference in mean age between groups (61.5 vs. 65.07; p=0.335; diagnosis was predominantly OA in both groups MOX-FQ: -  There were similar levels of pain (p=0.570), difficulty with walking / standing (p=0.492) and restriction in social activities (p=0.869) reported Quantitative gait measures: -  For spatial parameters, there was no difference between groups; p>0.05. -  For temporal parameters, there was decreased step time(s) (0.67 vs. 0.61) and mid stance times (0.38 s vs. 0.30 s) in Group B; borderline statistical significance (p=0.052). -  There was increase in stride velocity measured in Group B (79.1 ± 22.7 m/s) compared to Group A (64.0 ± 18.1 m/s), (p=0.05). Conclusion: -  Although there were no differences in functional levels of pain, difficulty with walking / standing and restriction in social activities, measured by MOX-FQ, there were differences observed in objective gait parameters. -  Patients in both groups demonstrated antalgic gait patterns; this was slightly increased in varus group. -  There is a trend for reduction in temporal parameters and stride velocity in patients with end stage ankle arthritis and coronal plane deformity >10?, when compared to patients with end stage arthritis and no coronal plane deformity -  Larger clinical study with increased sample size is required to confirm these findings.
Delayed presentation or delayed diagnosis? A retrospective study of prospectively collected data of 482 foot and ankle injury cases
Authors: Shah Rajiv 
Published: September 2018

Category: Trauma Introduction/Purpose: Delayed presentation of injury cases is common in developing countries due to lack of resources as well as lack of awareness. Such cases pose a great management challenge to clinicians. Study aimed to find out every possible responsible factor responsible for delayed presentations would guide towards targeted preventive measures. Foot and ankle orthopaedics being in infancy in developing country like India, foot and ankle injuries do present late. We took up a study to document and analyse the reasons for delayed presentations of foot and ankle injuries. Methods: Retrospective analysis of prospectively collected data from 482 foot and ankle injury cases treated at our three foot and ankle centres over past four years was done. Delayed presentation was defined as cases presenting to us at or after 3 weeks of injury and all these cases formed inclusion criteria. Delayed presenting cases without complete records and cases who were lost to follow up were excluded from this study. Reasons for delayed presentations were charted and further analysed. Results: Ninety eight delayed presenting cases (out of 482 cases) were divided in two groups. First group (28 cases) never got treated by orthopaedic surgeons, was labelled as ‘Direct delayed presentation group’. Second group (72 cases) who got treated by orthopaedic surgeons, but could not be diagnosed initially and presented late was labelled as ‘Indirect delayed presentation group’. Direct group cases initially followed home, quack or family physician’s remedies. Failure to suspect injury (5 cases) and failure to diagnose injury (67 cases) were reason subgroups in indirect group. Failure to diagnose injury was due to failure of clinico-radiological analysis (analytical failure (15 cases)) or due to failure of investigating case further (investigative failure (10 cases)). Forty two cases had combined analytical and investigative failures. Conclusion: In developing countries like India, many patients neglected their foot and ankle injuries and presented late. However clinicians were found to be more responsible for generating indirect delayed presentations by the way of failing to diagnose timely presented injury cases! This is contrary to common belief that in developing countries, patients would be solely responsible for delayed presentations! As delayed diagnosis by clinicians seemed more alarming than delayed presentation by patients, preventive education should also be imparted to clinicians over and above to patients. Study of such a scenario in developed countries would be interesting.
Total Ankle Arthroplasty with Simultaneous Versus Secondary Hindfoot Arthrodesis
Authors: Taylor Michel , Cody Elizabeth , Easley Mark , Parekh Selene , Nunley James , Adams Samuel 
Published: September 2018

Category: Ankle Arthritis Introduction/Purpose: Total ankle arthroplasty (TAA) for ankle arthritis leads to a more normal gait pattern compared to ankle arthrodesis, prompting many to hypothesize that TAA slows development of adjacent joint arthrosis. However, following TAA, patients may also develop hindfoot pain, deformity and dysfunction, ultimately requiring arthrodesis procedures. Many patients with AA also have subtalar and/or talonavicular arthrosis. In these cases, simultaneous TAA and hindfoot arthrodesis may be performed. Previous studies have found that TAA in conjunction with hindfoot arthrodesis procedures led to inferior outcomes compared to isolated TAA. The purpose of this analysis was to compare the functional outcomes of simultaneous vs. subsequent hindfoot arthrodesis procedures and to describe the change, if any, in outcome scores following a subsequent hindfoot arthrodesis procedure. Methods: After receiving Institutional Review Board approval, the TAA database at our institution was reviewed for all TAA performed between 1998 and 2015. All patients who received a TAA and either a simultaneous or subsequent hindfoot arthrodesis with at least two years of clinical follow up were included in the analysis. All surgeries were performed by one of three fellowship-trained orthopaedic foot and ankle surgeons with extensive experience in TAA and associated hindfoot arthrodesis procedures. Outcome measures included preoperative and 2-year postoperative visual analog scale (VAS) scores, Short Musculoskeletal Function Assessment (SMFA), Short Form (SF)-36 and American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scores. Results: 64 patients met the inclusion criteria. 39 patients underwent TAA with simultaneous hindfoot arthrodesis (Sim) and 25 underwent a subsequent arthrodesis procedure (Sub) an average 22.2 months following TAA. 20 patients underwent double arthrodesis (11 Sub) and 44 patients underwent subtalar fusion (14 Sub). There were no differences in preoperative questionnaire scores between the two groups. Both the Sim and Sub groups experienced significant improvement in their postoperative VAS, SMFA, SF-36 and AOFAS scores. Postoperative VAS and SMFA bother scores were significantly lower for the Sim group (p<0.05). In the Sub group, there was no difference in outcome scores before and after the fusion procedure. Demographics and questionnaire scores are shown in the Table. Conclusion: These results support previous findings demonstrating significant functional improvement and decrease in pain scores following TAA and associated fusion procedures. However, these results also suggest that simultaneous fusion procedures may provide better reduction in pain when compared to sequential procedures. In addition, for patients who underwent subsequent fusion, the improvement experienced in terms of pain and function tends to be maintained postoperatively.
A Comparison of Cost and Complications of Total Ankle Arthroplasty and Ankle Arthrodesis for the Management of Ankle Arthritis
Authors: Tucker William , Barnds Bandon , Mullen Scott , Schroeppel Paul , Vopat Bryan 
Published: September 2018

Category: Ankle Arthritis Introduction/Purpose: Ankle arthritis is a relatively common ailment that affects many people. The method of surgical management of this disease process is usually an ankle arthrodesis (AA) or a total ankle replacement (TAR). Traditionally, AA was viewed as the “gold standard”, however TAR has grown in popularity. Numerous studies have evaluated the risks and benefits of each of these treatments including satisfaction, biomechanics, and cost. The purpose of this study was to compare the cost and rate of complications for patients who underwent either an AA or TAR using a large database. Methods: Using the PearlDiver Technologies, Inc. database, Medicare patients who were diagnosed with ankle arthritis based on ICD-9 codes from 2005 to 2014 were analyzed. Patients were identified who underwent either AA or TAR utilizing ICD-9 procedure and CPT codes. These patient groups were evaluated for postoperative complications and reoperation rates. Subjects and associated costs were followed after the initial procedure. A cost analysis based on diagnosis and procedural codes was then performed on the separate groups, using a t-test to determine statistical significance. Data was analyzed with regards to standard demographic information as well as a metric of overall patient health status, the Charlson Comorbidity Index (CCI). Results: During the study period, 673,789 patients were identified with the diagnosis of ankle arthritis. Of those, 19,120(2.8%) underwent AA and 9,059 (1.3%) underwent TAR. While the yearly rate of AA performed remained stable, TAR was performed at increasing rates. The overall complication rate in the AA group was 24.9% with a 16.5% revision rate compared to 15.1% and 11.2% respectively in the TAR group (P<0.001). Also, the AA group had a higher total reoperation rate. The CCI was found to be significantly lower in the TAR group at 4.5 versus 4.7 in AA patients (P<0.001). Patients younger than 65 years old had both higher complication and reoperation rate. The average one-year cost associated with TAR was $12,566.15 and with AA was $6,967.32 (P<0.001). Conclusion: While TAR was found to be a more expensive treatment option than AA in this large-scale database study, patients in this group had significantly lower complication rates. The reoperation rates were also lower in the TAR group. The CCI was noted to be slightly lower in the arthroplasty group, meaning these patients may have been healthier, representing a selection bias. Also, the patients that had complications were found to have a higher CCI on average. When choosing surgical intervention for end-stage ankle arthritis, patients should be counseled on cost differences and potential complications for TAR and AA.
Augmented Reality Guided Osteotomy in Hallux Valgus Surgery
Authors: Wirth Stephan , Viehöfer Arnd , Laurenz Jaberg , Zimmermann Stefan , Dennler Cyrill , Fürnstahl Philipp , Farshad Mazda 
Published: September 2018

Category: Bunion Introduction/Purpose: An optimal osteotomy angle can avoid shortening of the first metatarsal bone after hallux valgus surgery and therefore reduce the risk of transfer-metatarsalgia. Up to date the osteotomy is performed free-hand without guidance and is therefore prone to unwanted variability in accuracy. The purpose of the present ex-vivo study was to investigate whether overlaying a hologram (augmented reality, AR) would improve accuracy of the distal osteotomy during hallux valgus surgery. Methods: A polyamide foot skeleton was constructed based a CT scan of a cadaveric foot and covered with medical silicon soft tissue. Three different polyamide first metatarsals were inserted to simulate a light, moderate and severe hallux valgus deformity. Distal Osteotomies of the first metatarsals were performed by two surgeons with different levels of surgical experience each with (AR, n=15x2) or without (controls, n=15x2) overlay of a hologram depicting an angle of osteotomy perpendicular to the second metatarsal in the transverse plane. Subsequently, the deviation to the plumb line of the second metatarsal in the transverse plane of all 60 osteotomies angles were optically measured and statistically analyzed. Results: Overall, the AR-guided osteotomies were more accurate (4.9 ± 4.2°) compared to the freehand cuts (6.7± 6.1°) by tendency (p=0.2). However, while the inexperienced surgeon performed more accurate osteotomies with AR with a mean angle of 6.4± 3.5° compared to freehand 10.5 ± 5.5° (p=0.02), no significant difference was noticed for the experienced surgeon with an osteotomy angle of around 3° in both cases. Conclusion: This pilot-study suggests that augmented reality guided osteotomies can potentially improve accuracy during hallux valgus surgery, particularly for less experienced surgeons. However, clinical studies are needed to investigate the clinical benefit of augmented reality in hallux valgus surgery.