bluuebunny/crossref_metadata_2025_split huggingface dataset:
20 Degree Post Traumatic Ankle Valgus and Distal Lateral Tibial Osteonecrosis Treated with Staged Deformity Correction and Total Ankle Arthroplasty
Authors: DiDomenico Lawrence , Butto Danielle 
Published: September 2017

Category: Ankle, Ankle Arthritis Introduction/Purpose: The purpose of this review is to present a case of post-traumatic ankle valgus and distal lateral tibial osteonecrosis successfully treated with staged deltoid repair, opening wedge tibial osteotomy, fibular lengthening, syndesmotic fusion and total ankle arthroplasty. Methods: Initial surgery consisted of ankle joint arthrotomy and deltoid imbrication. The second surgery consisted of a tibial opening wedge osteotomy with autogenous cortical fibular bone graft superior to the area of osteonecrosis to correct the 20 degree ankle valgus. Fibular lengthening osteotomy and fusion of the distal syndesmosis were also performed. CT scan confirmed bony consolidation at the distal tibiofibular syndesmosis as well as union of the allograft opening wedge. The final surgery was total ankle joint replacement with bone grafting of the area of osteonecrosis. Results: After 5 years of follow up the patient has progressed out of his AFO to full weightbearing. He reports no ankle pain, improved function and range of motion and is ambulating independently with no assistive devices. Conclusion: We successfully treated a case of distal lateral tibial osteonecrosis, and a 20 degree ankle valgus with staged deformity correction and ankle replacement. Radiographs demonstrate a well seated and positioned implant. We believe that with proper alignment that total ankle arthroplasty is a safe treatment option in the face of bone infarction.
The Effect of Orthotics on Ankle and Subtalar Joint Orientation and Load Distribution Utilizing a Novel System to Simulate Weight Bearing in a Cadaveric Model
Authors: Duggal Naven , Nazarian Ara , Nasr Michael , Williamson Patrick , Okajima Stephen , Lechtig Aron , Hanna Philip , Biggane Peter 
Published: September 2017

Category: Ankle, Basic Sciences/Biologics, Hindfoot, Biomechanics Introduction/Purpose: Orthotics are commonly prescribed by orthopaedic surgeons to address the hindfoot and midfoot deformity resulting from posterior tibial tendon dysfunction. The public however will often purchase over the counter orthotics for generalized complaints of foot pain that is not associated with any significant deformity or foot pathology. The mechanical axis of the lower limb may be altered in patients who use orthotics despite a normal foot alignment. We hypothesize that patients with normal alignment who use orthotics may adversely change ankle and subtalar joint orientation and load distribution. Methods: Five fresh frozen lower limb cadaveric specimens without known skeletal condition were used. The femoral head was potted with PMMA and TekScan pressure sensors were inserted into the ankle and subtalar joint. The specimens were placed on a custom jig, which allowed for load cell modulated loading of the leg; 75 lb load (half body weight) was applied at the femoral head while the foot was supported against a fixed plate keeping the ankle in neutral position. Testing was achieved by placing an orthotic under the medial half of the plantar talonavicular joint level. Mean pressure (MP), peak pressure (PP), contact area (CA), and center of force (COF) were measured in both the ankle and subtalar joints under three conditions; barefoot (BASE), with a 1.5 cm (ORT1) and 3 cm (ORT2) height orthotic. Each condition was tested three times per specimen. Displacement of COF was calculated relative to its location at baseline. Results: The MP, PP and CA showed a constant decrease from BASE to ORT1 and ORT2. Despite this relation, the only comparison that was significantly different was that between peak pressure values of the baseline and ORT2 conditions of the subtalar joint. The average displacement of COF from BASE was 0.14 mm and 0.42 mm medially, and 0.26 mm and 0.46 mm posteriorly at the ankle joint with ORT1 and ORT2 respectively. The average displacement of COF from BASE was 0.03 mm laterally and 0.08 mm posteriorly with ORT1, and 0.2 mm medially and 0.46 mm posteriorly with ORT2 at the subtalar joint. Conclusion: Foot deformities have an impact on the articular forces in the lower limb. Our results agree with previous studies about the role of foot deformity on the distribution of body weight forces and its consequences across the ankle and subtalar joint. Our novel study also demonstrates that orthotics and orthotics of varying sizes can change the mean pressure, peak pressure, contact area center of force in the ankle and subtalar joint. This study proves the feasibility of its design for studying intra-articular pressure changes in a lower limb cadaveric model with simulated weight bearing.
Patients’ Expectations of Foot and Ankle Surgery
Authors: Ellis Scott , Cody Elizabeth , Koltsov Jayme , Marinescu Anca , Mancuso Carol 
Published: September 2017

Category: Patient expectations Introduction/Purpose: Patients’ expectations from orthopaedic surgery may strongly affect postoperative satisfaction and have been shown to relate to many different factors, including age, sex, functional status, and health. However, the diverse diagnoses in foot and ankle surgery may also influence expectations. While pain relief tends to be the predominant expectation of orthopaedic foot and ankle patients, there are certain expectations that may be more important for patients with certain diagnoses. In this study, we aimed to analyze differences in patients’ expectations among the major surgical diagnoses seen in foot and ankle practices. Methods: 352 patients undergoing elective foot and ankle surgery by six orthopaedic foot and ankle surgeons were enrolled over eight months. Patients completed the Foot & Ankle Surgery Expectations Survey preoperatively, as well as the Foot & Ankle Outcome Score (FAOS), Short Form (SF)-12, Patient Health Questionnaire (PHQ)-8, Generalized Anxiety Disorder 7-item scale (GAD-7), and pain visual analog scale (VAS). The expectations survey is scored from 0-100 with higher scores indicating greater expectations. Each of its 23 items can also be assessed independently. Differences in expectations scores between diagnoses were analyzed with t-tests and analysis of variance (ANOVA). Differences in the number of expectations and number of expectations with complete improvement expected were analyzed with Mann-Whitney U and Kruskal Wallis tests. Results: Patients with a diagnosis of ankle instability or osteochondral lesion (OCL) had higher expectations scores (p = 0.004) and more often expected complete improvement (p = 0.024) compared to patients with other diagnoses (Table). Patients with hallux valgus had lower expectations scores (p = 0.005) than patients with other diagnoses. Patients with mid- or hindfoot arthritis also had lower expectations scores (p = 0.006) and even more significantly, had an average of only 2.4 expectations with complete improvement expected, while all other patients averaged 8.4 (p < 0.001). Expectations that were relatively unique to specific diagnoses included increased shoe variety for hallux valgus and hallux rigidus, improved appearance for hallux valgus, and improved ability to run for exercise for ankle instability or OCL. Conclusion: Patients’ expectations of foot and ankle surgery vary widely by diagnosis. Higher expectations among patients with ankle instability/OCL may be related to worse functional and mental health status (Table). Lower expectations among patients with hallux valgus and mid- or hindfoot arthritis may be attributable in part to patients’ recognition of the difficulty of treating their condition. Preoperative counseling by their surgeons regarding realistic expectations may also be a factor. We can use the findings of this study to predict what expectations are most important to patients with different diagnoses and to guide how we counsel them prior to surgery.
Outcomes Following Nonoperative Treatment of Isolated Posterior Malleolar Ankle Fractures
Authors: Finney Fred , Kuhn Andrew , Sheibani-Rad Shahin , Charpentier Paul , Holmes James , Bedi Asheesh 
Published: September 2017

Category: Ankle, Trauma Introduction/Purpose: Ankle fractures are common injuries, however isolated posterior malleolar fractures are rare. Axial loading of the foot in hyper-plantarflexion is thought to be the most likely mechanism of injury for this fracture pattern. Management of isolated posterior malleolar fractures presents challenges for clinicians, and controversy exists over surgical indications. The literature to-date examining isolated posterior malleolar fractures is scarce and confined to case reports and small clinical series. Recommendations for surgical treatment are based largely on biomechanical studies and not clinical evidence. The purpose of this study was to assess outcomes in a series of patients, who were consecutively treated nonoperatively for isolated posterior malleolus ankle fractures. Methods: Outcomes of patients with isolated posterior malleolus fractures who were all treated nonoperatively at two academic teaching hospitals were retrospectively reviewed. The size of the posterior malleolar fracture fragment was measured on lateral ankle radiographs, and clinical outcomes were evaluated using the American Academy of Orthopaedic Surgeons (AAOS) Foot and Ankle Survey. These scores were then compared to published normative data from the general population via independent t-tests. These same outcome measures were then correlated with the size of the posterior malleolar fragment via Spearman Rank Correlations. Results: A total of 28 patients (17 male, 11 female) were retrospectively reviewed. The average size of the posterior malleolus fragment was 16.0% (Range: 2.0-59.5%) of the tibial plafond articular surface. The average follow-up duration was 2 years and 7 months. At follow-up, the average “Foot and Ankle Core Score” and “Shoe Comfort Scale Score” were 90 (±11.2) and 80.0 (±28.9), respectively. When these scores were compared to normative data from the general population, no significant differences were found (Foot and Ankle Core Score: p=0.234, Shoe Comfort Scale: p=0.276). There was also no significant association between these scores and the size of fracture fragment. At follow-up, no patients demonstrated signs of instability, dermatological complications, malalignment of the mortise or post-traumatic arthritis. Conclusion: This is the largest study to date evaluating outcomes of isolated posterior malleolus fractures in patients treated nonoperatively. This series of 28 patients with isolated posterior malleolar fractures managed nonoperatively demonstrates short- to mid-term functional outcomes that are no different than reported normative data for the general population. These findings are consistent with previously reported clinical outcomes and suggest that nonoperative management is a viable treatment option for isolated posterior malleolar fractures.
The Cavovarus Foot and It’s Association with Fractures of the Fifth Metatarsal
Authors: Fuchs Daniel , Kane Justin , Brodsky James , Royer Christian , Zide Jacob , Reddy Veerabhadra , Bhimani Aamir , Daoud Yahya 
Published: September 2017

Category: Midfoot/Forefoot, Trauma Introduction/Purpose: Fifth metatarsal fractures are the most commonly encountered metatarsal fractures. It is often inferred that fifth metatarsal fractures occur at an increased frequency in patients with cavovarus foot position. In particular, zone 2 and zone 3 fractures are thought to be associated with cavovarus feet. However, limited data exists in the literature to support this claim. The hypothesis of this study is that a cavovarus foot alignment is positively correlated with the incidence of fifth metatarsal fractures. Methods: 298 consecutive fifth metatarsal fractures were compared with a matched control group of 104 patients presenting to an orthopaedic clinic for toe fractures, interdigital neuromas and plantar fasciitis. Radiographic parameters were measured on weight-bearing anteroposterior and lateral x-rays for all patients. An ANOVA test was utilized to compare radiographic parameters between patients with fifth metatarsal fractures and the control group. Parameters that were found to be statistically significant were further analyzed using a Tukey-Kramer test to compare controls and each type of fifth metatarsal fracture (zone 1, zone 2, zone 3, distal oblique diaphyseal, metatarsal neck). Results: All radiographic parameters are listed in table 1. A statistically significant difference (p<0.05) for calcaneal pitch, lateral talocalcaneal angle, AP talo-2nd metatarsal angle, talonavicular coverage angle and AP talocalcaneal angle were detected. All parameters are indicative of increased cavovarus in the fifth metatarsal fracture group when compared with controls. In the subgroup analysis, zone 1, zone 2, zone 3 and distal oblique diaphyseal fractures each had a calcaneal pitch, lateral talocalcaneal angle and AP talocalcaneal angle consistent with a more cavovarus position than the control group (p<0.05). Zone 2 and zone 3 fractures had an AP talo-2nd metatarsal angle more consistent with cavovarus than zone 1 fractures and controls. For all other parameters there were no significant differences between each type of fifth metatarsal fracture. Conclusion: While it is commonly accepted that cavovarus is a risk factor for fifth metatarsal fractures, there’s little evidence in the literature to support this. This study is the first to show that there is a positive correlation between radiographic parameters that reflect cavovarus foot position and the incidence of fifth metatarsal fractures compared to a matched control group of patients with unrelated pathology. Furthermore, while zone 2 and zone 3 fractures are most commonly thought to be associated with cavovarus, each subcategory of fifth metatarsal fractures in this study had radiographic measurements more consistent with cavovarus foot position than controls.
Particulate Umbilical Cord/Amniotic Membrane for the Treatment of Plantar Fasciitis
Authors: Garras David , Scott Ryan 
Published: September 2017

Category: Hindfoot Introduction/Purpose: Plantar fasciitis is the most common cause of heel pain, resulting in an estimated 1 million visits to medical professionals annually. Conservative treatments for plantar fasciitis include rest, orthotics, night splint, stretching and non- steroidal anti-inflammatory drugs. Such treatments are successful in nearly 90% of patients, however, more invasive treatments are required for patients whose heel pain symptoms persist greater than six months. Fetal tissues, including the umbilical cord (UC) and amniotic membrane (AM) have been increasingly used to modulate healing in different parts of the body over the last two decades. These tissues have been demonstrated to possess anti-inflammatory and anti-scarring properties in addition to containing growth factors, cytokines, and matrix components to promote healing, and offer a potential therapy for plantar fasciitis. Methods: In this clinical series, we sought to evaluate the efficacy of cryopreserved, particulate UC/AM tissues as a treatment for plantar fasciitis as well as to determine if multiple injections provide an even greater benefit compared to a single injection. A multicenter prospective study was performed where patients were randomized to receive 25, 50, or 100 mg UC/AM tissue and either a single injection or two injections (at baseline and six weeks). All injections were administered under ultrasound guidance into the plantar fascia. At six, 12, and 18 weeks, patients returned and data on foot pain as well as the FAAM questionnaire were collected. Results: Last year, we presented interim data on 18 patients who had completed 18 weeks of follow-up. This year, we present the completed results of the study. Overall, patient foot pain was found to be significantly reduced in all treatment groups from baseline. FAAM scores for both activities of daily living and sports subscales also improved in all treatment groups, with overall improvement ranging from 60 – 150% compared to baseline. All patients showed variable degrees of improvement with no patients showing any deterioration. Conclusion: The results of this case series are similar to the results of an earlier study which found that injection of a particulate human amniotic membrane product for plantar fasciitis was safe and comparable to corticosteroids. While all treatments demonstrated improvement in both foot pain and FAAM scores, there was both a dose dependent as well as injection dependent effect of particulate UC/AM tissue on foot pain reduction (100 mg > 50 mg >25 mg; 2 injections > 1injection) suggesting a possible additive effect. Overall, these results are promising and highlight the potential effectiveness of UC/AM tissues as a treatment for plantar fasciitis.
Radiographic Results of Intramedullary Nails for Lateral Malleolus Fractures
Authors: Garras David 
Published: September 2017

Category: Ankle, Trauma Introduction/Purpose: Plating the lateral malleolus yields predictable patient outcomes and anatomic reductions with an efficient surgical procedure. However, large incisions and prominence result in wound complications in 5% to 16% of patients. Although rudimentary intramedullary fixation has been applied for these fractures for decades, new intramedullary devices have become available with broader indications. These nails have the promise of holding accurate reductions and faster patient rehabilitation with virtually non-existent wound issues due to the minimal incisions required for implantation. The aim of this study was to determine if a new intramedullary nail could provide radiographically sound reductions while reducing wound complications and providing faster rehabilitation in a variety of ankle fracture classifications. Methods: We retrospectively reviewed the x-rays of 40 ankle fracture patients repaired by two surgeons at different institutions from March 2015 through October 2016. Patients were followed for a minimum of six weeks. Radiographs were reviewed for fracture healing, mortise alignment and fibular length (figure 1). The group was comprised of usual fracture patterns SER 2, 3,4, PER, uni bimalleolar and trimalleolar. Most reductions were performed percutaneously, however a small-incision was used to reduce older fractures or those that could not be reduced without direct visualization. Results: All fractures appeared to have complete union and radiographically anatomic reductions. No wound infections presented, and patients experienced reduced pain with early weight-bearing. Conclusion: Modern intramedullary nails can deliver excellent results and provide an important part of a surgeon’s treatment armamentarium for lateral malleolus fractures. The nails are especially valuable for non-compliant patients or those with comorbidities that negatively affect skin healing.
Initial Fibular Displacement as a Predictor of Medial Clear Space Widening in Weber B Ankle Fractures
Authors: Geaney Lauren , Cavanaugh Zachary , Sathe Vinayak 
Published: September 2017

Category: Ankle, Trauma Introduction/Purpose: The diagnosis of medial ankle instability in Weber B ankle fractures remains controversial. Manual stress radiographs are considered by many to be the gold standard to assess deltoid ligament integrity (Tornetta 2000). Gravity stress examinations have been shown to be equivalent (Gill 2007, Schock 2007), and also offer the advantage of causing less patient discomfort (Schock 2007). Significant fibular displacement likely serves as a surrogate for the large amount of energy required to tear the deltoid ligament. Therefore, the purpose of this study was to determine the relationship between initial fibular displacement and medial clear space widening on a gravity stress radiograph. Methods: A retrospective review was conducted of all patients with isolated Weber B ankle fractures with both initial injury radiographs and gravity stress view from August 1st, 2014 through April 1st, 2016. A total of 17 subjects were identified, age 42.6±17 years, time to GSV 4.6±5 days. On the mortise view of injury radiographs, medial clear space (MCS), superior clear space (SCS), lateral fibular displacement (LFDP) and fibular shortening (FS) were measured, and on the lateral view, anterior to posterior fibular gap (A to P FG) was measured. The gravity stress view was used to measure the medial clear space widening (MCS-W). All statistical analysis was performed using Stata (College Station, TX). T-tests were used to calculate mean and standard deviation of each group, correlation and linear regression analyses were run with each displacement variable relative to MCS-W. ROC analysis was used to determine sensitivity and specificity of the displacement variables. Results: Strong significant correlations with MCS-W were found for LFDP (0.69, p=0.003), and A to P FG (0.72, p=0.001), but not with FS (0.34, p=0.18). Linear regression analysis revealed significant ability to predict MCS-W for both LFDP (coefficient=1.12, R2=0.48, p=0.002) and A to P FG (coefficient=2.57, R2=0.52, p=0.001) but not FS (coefficient=0.67, R2=0.11, p=0.18). When LFDP and A to P FG were combined, they accounted for 65% of the variability in MCS-W (coefficient=0.70, 1.76; R2=0.65, p=0.033, p=0.018). ROC analysis for A to P FG using cutoff values of 0.75 mm, 1.0 mm, and 1.25 mm yielded SN and SP of 100% and 75%, 100% and 100%, and 67% and 100%, respectively for each cut point. Conclusion: The initial fibular displacement is a strong predictor of medial clear space widening in Weber B ankle fractures. On lateral radiographs, an anterior to posterior fibular gap greater than 1.0 mm showed a sensitivity and specificity of 100% in predicting MCS-W=5.0 mm. This provides another tool to aid clinicians in determining the integrity of the deltoid ligament and may help prevent the need for further patient discomfort with a stress view.
High Variability of Observed Weight Bearing During Standing Foot and Ankle Radiographs
Authors: Ghorbanhoseini Mohammad , Miller Christopher , Kwon John Y. , Walley Kempland , Ghaheri Azadeh 
Published: September 2017

Category: Basic Sciences/Biologics, Trauma Introduction/Purpose: Weight bearing radiographs are a critical component of evaluating foot and ankle pathology. An underlying assumption is that patients are placing 50% of their body weight on the affected foot during image acquisition. The accuracy of weight bearing during radiographs is unknown and, presumably, variable, which may result in uncertain ability of the resultant radiographs to accurately portray the pathology of interest. Methods: 50 subjects were tested. The percent body weight through the foot of interest was measured at the moment of radiographic image acquisition. The subject was then instructed to “bear ½ body weight” prior to the next radiograph. The percent body weight was calculated and compared to ideal 50% weight bearing. Results: The mean percent body weight in trial 1 and 2 was 45.7% ± 3.2% (p=0.012 compared to 50% mark) and 49.2% ± 2.4%, respectively (p=0.428 compared to 50%). The mean absolute difference in percent weight bearing compared to 50% in trials 1 and 2 was 9.3% ± 2.25% and 5.75% ± 1.8%, respectively (p=0.005). For trial 1, 18/50 subjects were within the “ideal” (45-55%) range for weight bearing compared to 32/50 on trial 2 (p=0.005). In trial 1 24/50 subjects had “appropriate” (>45%) weight bearing compared to 39/50 on trial 2 (p=0.002). Conclusion: There is substantial variability in the weight applied during radiograph acquisition. This study raises significant questions about assumptions we, as orthopaedic surgeons, have made regarding weight bearing radiographs, their reliability and how we should proceed when evaluating them.