bluuebunny/crossref_metadata_2025_split huggingface dataset:
Release of Tibialis Posterior Muscle Osseofascial Sheath for Chronic Exertional Compartment Syndrome Leads to Improved Outcomes
Authors: Boissonneault Adam , Bellamy Taylor , Labib Sameh 
Published: September 2018

Category: Sports Introduction/Purpose: Success rates for surgical management of chronic exertional compartment syndrome (CECS) in the lower extremity are influenced by the leg compartment involved. A failure rate of 40-50% has been associated with release of the deep posterior compartment, which has historically been associated with significantly worse outcomes than isolated anterolateral releases. The tibialis posterior muscle often resides in a separate osseofascial sheath, the so-called “fifth compartment.” At our institution, when a deep posterior release is performed, we routinely examine for this fifth compartment and release it if present. Within the context of this surgical approach, the aim of the current study was to compare long-term patient satisfaction and activity levels in those that underwent 2-versus 4-compartment fasciotomy for CECS. Methods: Our study reports on 48 limbs from 31 patients associated with a consecutive series that presented to a single institution for surgical management of lower extremity CECS from 2007-2016. The mean (standard deviation) follow-up was 65 (+/- 28) months. All patients underwent pre-operative intramuscular compartment pressure testing for CECS diagnosis. All surgeries were performed by a single surgeon. In all patients in which 4-compartment fasciotomy was indicated, the tibialis posterior muscle was examined for a separate osseofascial sheath. This sheath was released when present. The presence or absence of the sheath was always dictated in the operative note. Patient satisfaction outcomes were assessed with a Likert scale (excellent, good, fair, or poor). Current activity level was assessed via Marx and Tegner activity scores. Results: Of the 48 limbs, 29 limbs received 2-compartment anterolateral releases only and 19 limbs received 4-compartment fasciotomies. Of those that received 4-compartment fasciotomies, 13 (68%) were found to have a separate osseofascial sheath surrounding the tibialis posterior muscle. At a mean 5-year follow-up interval, 77% of the total cohort rated their outcome as good or excellent. Among the 4-comparment fasciotomy sub-cohort, 79% of patients rated their outcome as good or excellent. Among the entire cohort, there were no revision surgeries performed. The overall mean Tegner and Marx activity scores were 6 and 11 respectively. There was no significant difference in mean outcome scores between those that had 2-versus 4-compartment fasciotomies. Conclusion: Our study illustrates that 1) a separate osseofascial sheath exists around the tibialis posterior muscle in the majority of cases and 2) if this fifth compartment is consistently examined for and released, patients can achieve equivalent success rates and return to a similarly high activity level as those that undergo 2-compartment fasciotomy for CECS. Our study demonstrates superior results for 4-compartment release and includes the longest mean follow-up time for CECS patients in the literature.
The Effect of Patient Comorbidities on Intermediate Outcomes After Total Ankle Arthroplasty
Authors: Cunningham Daniel , Nunley James , DeOrio James , Easley Mark 
Published: September 2018

Category: Ankle Introduction/Purpose: Total ankle arthroplasty (TAA) has shown durable improvements in pain, function, and quality of life. Patient factors could affect intermediate to long-term outcomes after total ankle arthroplasty, and the impact of common medical comorbidities has not been fully characterized. The purpose of this study was to determine if common preoperative patient comorbidities had an effect on patient outcomes. Methods: Patients undergoing TAA between 1/2007 and 12/2016 were enrolled into a prospective study at a single academic center. Patients completed the following outcome measures before surgery and then in follow-up: AOFAS Hindfoot score, 36-item Short Form Survey (SF-36), Foot and Ankle Disability Index (FADI), and the Short Musculoskeletal Function Assessment (SMFA) score. Patient and operative factors along with pre-operative Charlson-Deyo and Elixhauser comorbidities with at least 10% prevalence across the entire population were assessed for association with changes in outcomes from pre-operative to the patient’s most recent follow-up. A minimum of 2 years of follow-up was required. Factors that met a significance threshold of p<0.05 in univariate analyses were incorporated into multivariable outcome models. Results: A total of 538 patients with an average follow-up of 4.3 years (range, 2 to 10 years) were included. While patients had significantly improved pain and function across all outcomes, smoking was associated with smaller improvements in AOFAS hindfoot score, AOFAS hindfoot function subscale, SF-36 physical summary scale, SF-36 total scale, and SMFA function scale. Prior foot and ankle surgery was associated with smaller improvement in AOFAS hindfoot pain subscale as well as VAS pain. Rheumatoid arthritis was associated with smaller improvement in SF-36 total and physical summary subscale scores while obesity was associated with smaller improvement in the FADI. Smoking had the largest impact on results, and produced a moderate effect size. All other variables had trivial to small effect sizes. Conclusion: While patient outcomes improved significantly after TAR at intermediate duration follow-up, smoking, prior surgery, rheumatoid arthritis, and obesity were risk factors for reduced improvement in outcomes. Smoking was associated with a moderate effect size, but all other factors had only small impact on patient-reported outcomes. Active smokers should be counseled on their risk of smaller improvements in outcomes, and it may be inadvisable to perform TAR on these patients.
Forefoot Striking Is More Effective in Reducing Loadrates than Increasing Cadence in Runners
Authors: Futrell Erin , Davis Irene 
Published: September 2018

Category: Sports Introduction/Purpose: Vertical impact forces are highly influenced by the way the foot contacts the ground. These impact forces are associated with high loading rates which have been related to running injuries. As a result, clinicians have begun to use gait retraining interventions to reduce loadrates and prevent future impact-related injuries. Two types of gait retraining techniques have been promoted to reduce excessive running impacts. The first involves increasing cadence (CAD), or number of steps per minute, by 5-10%, thereby reducing stride length. The second type of gait retraining involves landing on the ball of the foot at ground contact, or using a forefoot strike (FFS). Both of these gait-retraining styles have been reported to reduce impacts, but they have not been compared with each other. Methods: 33 healthy runners (9M, 24F), running 5-15 mpw, with a rearfoot strike pattern with cadence < 170 steps/min were recruited. Subjects were randomly allocated to either FFS or CAD retraining. All subjects underwent an 8-session gait retraining program (over 2-3 wks) with auditory feedback on a treadmill. The CAD group ran to a digital metronome to increase cadence by 7.5%. The FFS group wore a wireless accelerometer that provided an auditory signal on footstrike pattern. A gait analysis was conducted at baseline, 1 wk, 1 month, and 6 months. Variables included vertical average and instantaneous load rates (VALR, VILR). A 2 x 4 repeated measures ANOVA was used to compare differences within and between the CAD and FFS groups at baseline, 1 week, 1 month and 6 months post retraining. For variables with significant interactions, simple main effects of group, as well as time were further explored using one-way ANOVA Results: There were significant interaction effects of time*group for VALR (p= 0.001), VILR (p=0.001) and foot angle (p< 0.001), but not cadence. For the simple main effects for the CAD group, VALR reduced by 14%, 7% and 16% at 1 week, 1 month, and 6 months post gait retraining respectively, compared with baseline (Figure 1). However, these reductions were not significant. For the FFS group, VALR was significantly reduced by 50%, 51% and 51% at 1 week, 1 month, and 6 months post gait retraining respectively. Interestingly, both the CAD and FFS groups increased cadence by similar amounts. Conclusion: Transitioning to a FFS pattern is significantly more effective than increasing CAD when reducing vertical loadrate (both VALR and VILR) is the goal. These changes persisted out to 6 months post gait retraining, suggesting permanence of the new pattern.
The Effect of Age in Total Ankle Replacement
Authors: Gaugler Mario , Hintermann Beat , Schweizer Christine 
Published: September 2018

Category: Ankle Introduction/Purpose: Over the last decades, total ankle replacement (TAR) emerged as a reliable treatment option in end-stage ankle osteoarthritis (OA) while preserving motion and physiological load. As these are strong arguments for TAR from an active patient’s perspective, it appears obvious that young patients show great interest in it. In the late 90s, 2nd generation implants showed a high revision rate, which has led to great cautiousness for TAR in young and active patients. Despite recently published data on 3rd generation implants showed a comparable outcome within different age groups, the question to debate remains whether TAR is advised in younger patients. The purpose of this study was to compare the clinical outcome and revision rate after TAR in patients younger and older than 50 years. Methods: A consecutive series of 813 primary TARs (3rd generation HINTEGRA, 446 male, 367 female), performed between May 2003 and December 2013, were enrolled. 129 patients (16%) were younger than 50 years and 784 (84%) were older than 50 years at time of surgery. The clinical outcome (AOFAS hindfoot score) and survivorship (revision of a metallic component as endpoint, or ankle fusion) of patients aged <50 years and ≥50 years at the time of surgery were compared. Results: Posttraumatic OA as indication for a TAR was more common in the younger cohort (81 vs. 78%) and the mean follow-up time was slightly longer (5.6 vs. 5.0 years). Younger patients had a significantly lower preoperative AOFAS score (39 vs. 44). Both groups showed an identical clinical improvement that resulted in a lower total AOFAS score (66 vs. 71) in the younger group at last follow-up. Overall, a total of 81 ankles (10%) were revised (13 patients <50 years, 68 patients ≥50 years). In 62 ankles (77%) a revision of a metallic component, in 19 ankles (23%) a conversion to ankle fusion was performed. The estimated 10-year revision rate was 15.7% for patients aged > 50 years and 18.4% for patients aged ≥ 50 years. Conclusion: Beside of the higher incidence of posttraumatic OA in younger cohort, the high activity level and biomechanical demands may lead to a greater subjective limitation, which explains their significantly lower baseline AOFAS score. However, both groups showed similar clinical improvement and overall revision rates. Our findings support and back up recently published data from 3rd generation TARs to be an effective and reliable treatment option in end-stage ankle OA in young patients. However, a long-term follow-up and individual analysis of all failures leading to revision is of high importance.
Flecting Osteotomy of the Distal Tibia for Salvage of an Asymmetric Osteoarthritic Ankle Joint
Authors: Hintermann Beat , Scheidegger Patric , Lang Tamara Horn , Zwicky Lukas 
Published: September 2018

Category: Ankle Arthritis Introduction/Purpose: Deformity of the distal tibia in the sagittal plane with increased posterior tilt of the articular surface (recurvatum deformity) results in altered biomechanics and high contact pressure in the anterior tibiotalar joint with consecutive osteoarthritis (OA). As the talus becomes anteriorly extruded out of ankle mortise, the distance between its center of rotation and longitudinal axis of tibia is typically seen to be increased. In an attempt to restore physiologic load of such misaligned ankles in the sagittal plane, we have started to use a correcting osteotomy of the distal tibia to realign the center of rotation of talus and tibial axis. The aim of this study was to analyze the radiological and clinical outcome in a consecutive series of patients. Methods: 39 patients (female, 12; male 27; age 47 [28 to 72, SD 10.6] years) were treated with a flecting osteotomy of the distal tibia for a symptomatic misalignment in the sagittal plane with the use of an anterior opening wedge osteotomy (n = 28), posterior closing wedge osteotomy (n = 9), or dome-shaped osteotomy from medially (n = 2). If necessary, simultaneous corrections in the frontal plane were performed to address additional valgus/varus deformities. Standard weight-bearing radiographs were used pre- and postoperatively to evaluate the tibial anterior surface angle (TAS), tibiotalar surface angle (TTS), tibial lateral surface angle (TLS), calcaneal pitch and talar offset ratio (TOR). A four-staged flecting score was used to classify the grade of OA of the tibiotalar joint in the sagittal plane, also taking the coronal joint congruency into account. Results: The cumulative survival rate of the joint was 77% (95% CI: 48-86%) after 3 years, with 9 patients needing a joint sacrificing procedure (total ankle arthroplasty, 7; ankle fusion, 2). In the remaining 30 patients, pain decreased 2.0 points on the VAS (p <0.001), and the AOFAS hindfoot score improved by 17 points (p<0.001). The ROM did not change significantly. Patient satisfaction with the outcome was good in 68% and moderate in 25%, 7% were not satisfied. The mean TLS increased by 6.6 (SD 5.84) degrees, the mean TOR decreased 0.239 (SD 0.1814). TAS, TTS and calcaneal pitch did not change significantly. Ten ankles (26%) showed an improvement, 22 (56%) no change and 7 (18%) a worsening in the flecting score. Conclusion: The flecting osteotomy of the distal tibia was found to be an effective method to restore the tibiotalar joint congruency through moving the tibia axis anteriorly to the center of rotation of the talus, and lengthening the lever arm of the Achilles tendon. Besides normalizing the joint reaction forces of the tibiotalar joint, the procedure was also found to be effective to stabilize the talus against anterior extrusion. However, with a failure rate of 23%, there is need for further studies to determine the indication and limitation of this procedure.
Reliability and Validity of Scores from the Foot and Ankle Ability Measure
Authors: Matheny Lauren , Clanton Thomas 
Published: September 2018

Category: Ankle Introduction/Purpose: A commonly used measure of ankle function is the Foot and Ankle Ability Measure (FAAM). To support interpretation of the FAAM, evidence of reliability and validity must be established. Some studies have assessed FAAM scores; however, these studies had small sample sizes, sample characteristics that may limit generalizability, and did not report reliability estimates. These studies were also unable to account for person ability and item difficulty, a unique feature Rasch modeling offers, which is key when attempting to generalize to other populations. The purpose of this study was to determine whether there is evidence of reliability and validity for the FAAM ADL and Sport scales, utilizing the Rasch model, in patients who have undergone surgical intervention for the treatment of an ankle injury. Methods: Evidence of reliability and validity were determined utilizing the Rasch measurement model, a special case of item response theory, which has been used to develop new patient reported outcome measures and improve existing measures. This is a widely used technique that may be used as an alternative to classical test theory due to advantages including generalizability across samples, accounting for response options not equally spaced in terms of ability, and identifying poorly functioning items. The scale of interest is measured in terms of item difficulty and generates estimates of locations of individual items (item difficulty) and ability level along a common interval-level scale (log-odds). To identify misfit items, outfit mean-square (MNSQ) and infit MNSQ statistics were assessed. Infit and outfit MNSQ range from 0 to positive infinity (ideal value of 1.0 means observed variance = expected variance; acceptable value range 0.5 -1.7). Person reliability was also reported (analogous to Cronbach’s a). Results: There were 456 patients included in the study(192 females, 264 males)(average age=47.6 years(18-79). Rasch analysis showed good evidence of reliability for FAAM ADL and FAAM Sport scores (Figure 1). Person reliability was 0.87 for FAAM ADL and 0.89 for FAAM Sport. Outfit MNSQ values for FAAM ADL items 11 (Coming Up On Toes) and 10 (Squatting) were high (2.17, 1.96). Item 19 “Light/Moderate Work” was low(0.48), indicating item redundancy. For FAAM Sport, all outfit values (range 0.67 -1.64) were within the acceptable range. For internal scale validity, infit MNSQ values for FAAM ADL items 11 and 10 were high(2.30, 2.05). All other infit values (range 0.61 -1.48) were within the acceptable range. For FAAM Sport, all infit values (range 0.74 -1.65) were within the acceptable range. Conclusion: This study provides good evidence of reliability for FAAM ADL and Sport scores in a wide range of patients who underwent ankle surgery, which may demonstrate wide clinical applicability. Both scales demonstrated good internal scale validity; however, 3 FAAM ADL items may indicate the need for further scale development for use in a diverse ankle population.
Fixation of Ankle Fractures
Authors: Molloy Andrew , Whitehouse Samantha , Mason Lyndon 
Published: September 2018

Category: Trauma Introduction/Purpose: Ankle fractures are one of the most common fractures. Historically these have been frequently treated by non-specialists and junior staff. In 2011 we presented high malunion rates, which have been mirrored in other departments work. We present the results of system changes to improve the results of ankle fracture fixation Methods: Image intensifier films were reviewed on PACS and scored based on the criteria published by Pettrone et al. At least two blinded assessors assigned scores independently. Patients clinical data was collected from medical records. In 2011 we presented the results of fixation in 94 consecutive patients (Group 1) from 2009. Following this there was period of education in the department to allow change. 68 patients (Group 2) were then reviewed from a 7 month period in 2014 Multiple system changes were introduced in the department including; new treatment algorithms, dedicated foot and ankle trauma lists and clinics, and next day review of all intra-operative radiographs by independent attending. Prospective data was collected on 205 consecutive cases (Group 3) from 01/01/15 – 09/30/16 Results: Patients in group 1 had a malreduction rate of 33%. The major complication rate in this group was 8.5% (8 patients); with only one of these occurred in a correctly reduced fracture. These complications included 4 revision fixations, 2 deep infections and 1 amputation. Following the period of re-education, in Group 2, the mal-reduction rate deteriorated to 43.8%. In this group the major complication rate was 10.9%; including 6 revision fixations and 1 ankle fusion. In Group 3, following overall system changes, the malreduction rate was 2.4%. This result is statistically significant. The major complication rate fell to 0.98%; 1deep infection and 1 amputation (in a polytrauma patient with vascular injury). This result is again statistically significant. Conclusion: Our initial results show that very poor results are a consequence when sufficient attention is not given to what are frequently considered to be ‘simple’ fractures. In group 2 we demonstrated that soft educational changes (eg presentations, emails) are ineffective in improving results. We have demonstrated that hard (institutional system) changes in our department provided statistically significant improvements. These changes allowed the correct surgeon for the fracture in both determining the treatment plan and operating. With these changes, malreduction rates fell from 43.8% to 2.4% and major complication rates from 10.9% to 0.98%
Knee Kinetics and Kinematics in Patients with Ankle Arthroplasty and Ankle Arthrodesis
Authors: Roney Andrew , Kraszewski Andrew , Fansa Ashraf , de Cesar Netto Cesar , Ellis Scott , Deland Jonathan , Levine David , Demetracopoulos Constantine 
Published: September 2018

Category: Ankle Arthritis Introduction/Purpose: Ankle arthritis is a debilitating problem, causing significant pain and functional limitations. Previous literature suggests patients treated with ankle arthroplasty (TAA) versus ankle arthrodesis (AA) may have better function and have lower risk for adjacent joint arthritis in the foot. However, there is little research on how these interventions impact proximal joints, such as the knee. The knee adduction moment (KAM) is a surrogate measure for the force experienced at the medial tibiofemoral compartment and is linked with the onset and progression of knee osteoarthritis. We hypothesized that patients with TAA and AA will exhibit altered frontal plane kinematics and kinetics in the affected limb compared to the contralateral unaffected side, and that the AA cohort will have a significantly greater KAM compared to TAA. Methods: Instrumented 3D walking gait was recorded in 10 TAA and 10 AA patients, minimum 2-year post-operatively. Subjects were demographically matched, had unilateral ankle arthritis and lacked complications such as adjacent joint arthritis, neuropathy or significant weight-bearing pain. The TAA patients had either a Salto-Talaris or INBONE prosthesis. Lower limb kinematic and kinetic data were measured with reflective skin surface markers and floor-embedded force plates at self-selected walking speeds. Average first and second peak KAMs [N-m/kg], KAM impulse [N-m-s/kg] and range-of-motion (ROM, [°]) were calculated on both the affected and unaffected limb for each patient. Group differences in KAM, impulse and ROM between TAA and AA interventions and the affected and unaffected limb were analyzed using a 2-sample unpaired t test. P-values less than 0.05 were considered significant. Results: See Table 1 for demographic and statistical analyses summary. Between the affected and unaffected limbs in each surgical cohort there were no significant differences in the KAM’s first and second peak or impulse (p>0.135) and no difference in the knee ROM in any plane (p>0.214). When comparing AA with TAA, the average first peak KAMs generated while walking were 0.07N-m/kg greater in the TAA treatment but that difference was not significant (p=0.429). The second peak KAM was, on average, 0.1N-m/kg greater within TAA patients but was also not statistically different from AA patients (p=0.594). The KAM impulse and ROM in all 3 planes were not different between intervention types (p>0.318). Conclusion: TAA and AA may not significantly affect ipsilateral knee kinetics and KAMs in short term follow-up. This study highlights the importance of continuing to study these parameters in larger cohorts of patients with longer follow-up to determine how our treatment of end-stage ankle arthritis may affect the incidence or progression of ipsilateral knee osteoarthritis.