bluuebunny/crossref_metadata_2025_split huggingface dataset:
Effectiveness of Lateral Soft Tissue Release of the 1st Metatarsophalangeal Joint Through a Medial Transarticular Approach – A Cadaver Study
Authors: de Cesar Netto Cesar , Shah Ashish , Hudson Parke , Sahranavard Bahman , Cone Brent , Araoye Ibukunoluwa , Lee Sung , Bergstresser Shelby , Johnson Michael , Johannesmeyer David , Jones Caleb 
Published: September 2017

Category: Bunion Introduction/Purpose: First metatarsophalangeal joint lateral soft tissue release is frequently performed during corrective surgery for hallux valgus deformity. Surgical approaches include an open dorsal approach as well as a medial transarticular approach. The medial transarticular approach avoids the need for a second incision while also attenuating the risk of avascular necrosis of the first metatarsal head. However, this method is limited by the poor visualization of the lateral structures through the joint. The objective of this study was to evaluate the effectiveness of the medial transarticular approach for lateral soft tissue release in the 1st metatarsophalangeal joint. Methods: Ten below-the-knee fresh-frozen cadaveric specimens were used (6 females, 4 males). The mean age was 73.4 years. Two specimens had moderate hallux valgus deformity. None of the samples had considerable degenerative changes of the first metatarsophalangeal joint. Lateral soft tissue release was performed using a single 2.5 cm medial incision. Lateral soft tissue release targeted the lateral collateral ligament, lateral capsule, adductor hallucis muscle tendon and lateral metatarsosesamoid suspensory ligament. A single surgeon performed all procedures. An extended lateral dissection of the 1st intermetatarsal space was carried out to examine the accuracy of the technique. Successful release of each targeted structure (4 total) was recorded for each specimen. Thus, the percentage of successful release was computed for each specimen. Injuries to important non-targeted structures were also registered. Results: All four targeted structures were successfully released (100%) in seven of the ten cadavers. Three out of four structures were released (75%) in one cadaver, while two of the four and one of the four targeted structures were successfully released in the other two cadavers (50% and 25% success respectively). Lateral collateral ligament was successfully released in all cadavers. Lateral joint capsule, adductor hallucis muscle tendon, and lateral metatarsosesamoid suspensory ligament were released in 80% of the specimens. 1st metatarsal head chondral and unintended release of lateral head of the flexor hallucis brevis occurred respectively in 40% and 50% of the procedures. No injuries to the flexor hallucis longus tendon, neurovascular bundle, deep transverse metatarsal ligament or chondral damage to the proximal phalanx were recorded. Conclusion: Lateral soft tissue release of the first metatarsophalangeal joint can be successfully performed through a medial transarticular approach. Inadvertent release of the lateral head of the flexor hallux brevis and chondral damage of the 1st metatarsal head are complications to be considered.
Efficacy of Particulated Juvenile Cartilage Allograft Transplantation for Osteochondral Lesions of the Talus
Authors: Dekker Travis , Hamid Kamran , Easley Mark , Steele John , Adams Samuel 
Published: September 2017

Category: Ankle, Arthroscopy, Basic Sciences/Biologics, Sports Introduction/Purpose: Symptomatic osteochondral lesions of the talus (OLTs) are difficult to treat. As such, a broad array of cartilage treatment options exist. Despite the various techniques, many patients require multiple procedures due to persistent pain, failure of cartilage adherence, or persistent mechanical symptoms. The cartilage replacement technique, particulated juvenile cartilage allograft transplantation (PJCAT), is a novel treatment option supported by the benefits of ease of application, no need for perpendicular access to the OLT, and the delivery of viable hyaline cartilage. However, there is minimal clinical data to support this treatment option. The purpose of this study was to determine the efficacy of PJCAT. Methods: After obtaining IRB approval, we conducted a retrospective review of patients that underwent PJCAT for the treatment of OLTs at a single academic institution. From 2012 to 2015, 18 patients were identified. However, one patient died of an unrelated cause and two patients were lost to follow-up leaving 15 patients (7 males and 8 females) whom had a minimum of 12 months of follow up (mean 34.6, range, 12-51 months). The mean age of this cohort was 32.7 years (15-48) at time of surgery with BMI average 29.9 (18.8-40.2). The primary outcome was failure of the procedure defined as: recurrent or worsening symptoms with corresponding imaging demonstrating delamination, and/or the need for a secondary cartilage restoration procedure. Variables studied included: size of lesion denoted by MRI, intraoperative size, etiology (traumatic versus atraumatic), location of lesion, sex, age, and history of prior surgery. Results: Failure of primary procedure as defined by continued pain with corresponding imaging and/or necessity of secondary cartilage procedure after use of PJCAT was 40% (6/15). Preoperative MRI size (188.7 +/- 81.7mm2 vs. 113.5 +/- 50.5mm2, p<0.05) was significant predictors of PJCAT failure. Furthermore, male sex was predictive of failure(p<0.05). Age, BMI, etiology, technique (open versus arthroscopic), history of prior surgery nor location were predictors of failure. Lastly, patients with lesions greater than 125mm2 area were at a statistically significant increased risk of clinical failure. Functional outcome scores were significantly better at final follow-up in the patients who had undergone successful treatment versus those who did not: AOFAS score (89.4 +/- 8.4 vs. 65.8 +/- 26.7) and FAOS total (77.9 +/- 13.2 vs. 47.9 +/- 24.8). Conclusion: These findings demonstrate the association of preoperative MRI lesion size, intraoperative lesion size and male sex as risk factors for failure of PJCAT setting of an already difficult to treat pathology.
Financial Impact of MRI in Treatment of Foot and Ankle Osteomyelitis
Authors: Divi Srikanth , Hynes Kelly , Dirschl Douglas , Lee Cody 
Published: September 2017

Category: Ankle, Diabetes, Hindfoot, Lesser Toes, Midfoot/Forefoot, Infection Introduction/Purpose: Osteomyelitis of the foot and ankle is a common condition with a high economic burden in the United States, particularly in the context of diabetes mellitus. The timely and accurate diagnosis of osteomyelitis is important to initiate treatment and possibly reduce overall healthcare costs. Plain radiographs are the initial study of choice given their widespread availability and low cost. Magnetic resonance imaging (MRI) is generally considered the most sensitive imaging modality for detecting osteomyelitis, however it is associated with significant cost and may not change overall treatment as compared to plain radiographs. The purpose of our retrospective study is to determine whether the use of MRI at our institution changed clinical decision making and calculate the financial impact in patients with foot and ankle osteomyelitis. Methods: We retrospectively identified patients at our tertiary care, academic center treated for a diagnosis of osteomyelitis using ICD-9 codes 730.07, 730.17, and 730.27. Demographic data including age, sex, race and ethnicity and patient comorbidities was collected. The use of plain radiographs, MRI, and any operative procedures up to 2 years after the index encounter for each patient were identified. An impact MRI was defined as an MRI that led to an operative procedure within the same admission encounter. The cost of an impact MRI was estimated using the equation: (average MRI cost)*(total MRIs/impact MRIs). Chi- squared test was used to statistically compare patients that underwent procedures in the MRI group vs. those in non-MRI group. Results: 619 patients undergoing osteomyelitis treatment between January 2009 and September 2015 at our institution were identified, of which 40.4% were female and 59.6% were male. 151 patients had a total of 227 MRIs of the lower extremity performed vs. 468 patients that did not have MRIs performed. Of the MRI cohort, 104/151 patients (68.9%) had subsequent operative procedures, whereas in the non-MRI cohort 299/468 patients (63.9%) had subsequent operative procedures (p = 0.26). Of the 227 MRIs performed, 85 were deemed impactful MRIs and 142 were deemed non-impactful MRIs. Average MRI cost at our institution for the lower extremity with and without contrast was $5069.75. Using our previous definition, the cost of an impact MRI was calculated to be effectively $13,539.21. Conclusion: MRI can be an effective modality in aiding the clinical diagnosis of osteomyelitis, however, it can be an unnecessary cost when not used to guide treatment. In our study, we did not find a significant difference in the operative rate between patients undergoing MRIs vs. those that did not. We also found that the effective cost of an MRI that led to a change in treatment was $13,539, almost 2.7 times higher than the average cost of an MRI at our institution.
Midfoot Charcot Reconstruction with Intramedullary Beaming
Authors: Ford Samuel , Jones Carroll P. , Davis W. Hodges , Cohen Bruce 
Published: September 2017

Category: Diabetes, Midfoot/Forefoot, Charcot Introduction/Purpose: Midfoot Charcot osteoarthropathy is characterized by non-infectious osteolysis that often leads to midfoot collapse and resultant ulceration. Deformity and ulceration often lead to deep infection and amputation. Midfoot reconstruction with intramedullary screws (beams) is a recently described technique that provides deformity correction and a stable construct without the extensive exposure required for plate fixation. The purpose of this study is to examine the clinical outcomes and complications of patients with midfoot Charcot managed with midfoot osteotomy, realignment arthrodesis, and stabilization using intramedullary beams. Methods: A surgical database query of a tertiary-care foot and ankle center was performed from January 2013 to July 2016 to identify patients with midfoot Charcot who underwent corrective osteotomy with internal beam fixation. 24 patients were identified and included in the final analysis. Patients with minimum one-year follow-up were evaluated with physical examination, weight-bearing radiographs, and patient-reported outcome measures (FAAM and VR-12). The primary outcome measure was defined as restoration of a stable, plantigrade, ulcer-free foot. Secondary outcome measures include quantitative angular correction, rates of reoperation, postoperative infection, and amputation. Results: Median age was 60 years, median BMI was 32.5, and 79% were diabetic. The lateral Meary’s angle median improved from -29° preoperatively to -20° on final postoperative radiographs (p=0.007). 39% of midfoot osteotomies were united on final radiographs. An ulcer-free, stable, plantigrade foot was obtained in 83% of patients. Deep infection developed in six (25%) patients. The presence of a preoperative ulcer was found to be predictive of postoperative infection (p=0.05); all six deep infections occurred in patients with preoperative ulceration. 62.5% of patients required reoperation. Three (12.5%) patients progressed to amputation at a median nine postoperative months. The final postoperative median FAAM scores was 19. The VR-12 median score was also 19 with the following breakdown: Physical Component – 30, Mental Component – 67. Conclusion: Results from the FAAM indicate that patients with midfoot Charcot are severely disabled overall, moderately disabled with activities of daily living, and mostly unable to participate in sport. Results from the VR-12 indicate that patients continue to have poor healthcare quality of life, even following Charcot reconstruction. Midfoot Charcot reconstruction with intramedullary beaming allows for restoration of an ulcer-free, plantigrade foot in most patients, but the complication rates are high, especially in patients with pre-operative ulceration. Despite a low bony union rate, improvement in the lateral Meary’s angle and clinical success is often obtainable with a relatively low amputation rate.
Total Ankle Arthroplasty
Authors: Francis Ara , Flavin Robert , Mohammed Khalid Merghani Saleh , Aljabi Yasser 
Published: September 2017

Category: Ankle, Ankle Arthritis Introduction/Purpose: Total Ankle Arthroplasty has been introduced relatively late in the modern era in comparison to hip and knee replacement. it suffered from poor outcomes initially leading to abandonment of the procedure in favour of ankle arthrodesis. The reasons for failure have been debated in the literature. The development of second generation implants, consisting of a three component design, has heralded a new era for Total Ankle Arthoplasty. The purpose of this study was to perform a biomechanical analysis of three commercially available Total Ankle Arthroplasty implants and a literature review to shed light on mechanisms of failure. Methods: Three commercially available ankle arthroplasty (STAR, Hintegra, Mobility) implants were tested using a specifically designed ankle simulator which replicated plantarflexion/ dorsiflexion and inversion/eversion movements. Different loads were applied to the implants which were put through 50,000 cycles at a rate of 1.4 Hz and bearings were removed for inspection. The followoing were conducted before, during and after testing - Visual inspection, Weight of implant, Optical Profile Projector and Scanning Electron Microscopy. A literature review was also performed to compare and contrast results seen elsewhere. Results: Biomechanical analysis revealed loss of congruency and wear of the polymer bearing surfaces with varying degrees across the three implants - STAR 7%, Hintegra 10% and Mobility 4%. This is supported by evidence in the literature that STAR and Hintegra implants suffer considerably from flattening of the polymer bearing surfaces and subsequent decrease in height. Conclusion: The above biomechanical analysis and literature review of these implants supports our senior author’s clinical experience that the main reason for failure is medial insufficiency and tibialis posterior dysfuction that cause increased demand on the implants ultimately leading to implant failure.
Accuracy and Measurement Error of the Medial Clear Space of the Ankle
Authors: Ghorbanhoseini Mohammad , Kwon John Y. , Metitiri Ochuko , Zurakowski David , Nazarian Ara 
Published: September 2017

Category: Ankle, Trauma Introduction/Purpose: Measurement of the medial clear space (MCS) is commonly used to assess deltoid ligament competency and mortise stability when managing ankle fractures. Lacking knowledge of the true anatomic width measured, previous studies have been unable to measure accuracy of measurement. The purpose of this study is to determine MCS measurement error and accuracy and any influencing factors. Methods: Using three normal trans-tibial ankle cadaver specimens, deltoid and syndesmotic ligaments were transected and the mortise widened and affixed at a width of 6 mm (specimen #1) and 4 mm (specimen #2). The mortise was left intact in specimen #3. Radiographs were obtained of each cadaver at varying degrees of rotation. Radiographs were randomized and providers measured the MCS using a standardized technique. Results: Lack of accuracy as well as lack of precision in measurement of the medial clear space compared to a known anatomic value was present for all three specimens tested. There was no significant differences in mean delta with regard to level of training for specimens #1 and #2; however, with specimen #3 staff physicians showed increased measurement accuracy as compared to trainees. Conclusion: Accuracy and precision of MCS measurements are poor. Provider experience does not appear to influence accuracy and precision of measurements for the displaced mortise. This high degree of measurement error and lack of precision should be considered when deciding treatment options based on MCS measurements.
Calcaneal Fracture Fixation Using a New Interlocking Nail Reduces Complications Compared to Standard Locking Plates
Authors: Herlyn Anica , Mittlmeier Thomas 
Published: September 2017

Category: Hindfoot, Trauma Introduction/Purpose: Surgical treatment of displaced intraarticular calcaneal fractures using a standard lateral extended approach for plate fixation is frequently complicated by wound healing complications and infections. This prospective matched- pairs analysis evaluates the new minimally-invasive calcaneal interlocking nailing technique in terms of reduction capacities, complication rates and functional outcome compared to standard locking plate fixation. Methods: 40 feet (20 feet/group; mean patient age 53 years, range 27-78) with displaced intraarticular calcaneal fractures were either treated with a calcaneal locking nail (LN) or locking plate (LP) and observed clinically and radiologically after 1.6 years. Follow-up included CT-based radiological assessment of reduction and functional evaluation according to the AOFAS Ankle- Hindfoot- Score and Foot Function Index (FFI). Results: Time for surgery did not differ between both groups (LN 93 min vs. LP 96 min). Inpatient treatment time was significantly reduced in the LN group (7.6 days vs. LP 11 days). Postoperative and follow-up radiographic imaging revealed adequate restoration of the calcaneal body in both groups. The remaining defect of the posterior facet was significantly smaller in the LN group (0.7 mm vs. LP 1.6 mm). The mean AOFAS Score was slightly better for the LN group with 71.6 points vs. 66.1 points (LP). In analogy, the FFI revealed better results for the LN group (27.3 points) than the LP group (30.8 points). No intraoperative complications but two postoperative infections with wound healing complications were observed in the LP group. Conclusion: The new calcaneal interlocking nail shows promising results in terms of reduction capacities and safety. Postoperative infection complications were reduced whilst superior function was found applying the minimum-invasive interlocking nailing technique compared with standard locking plate fixation via a lateral extended approach.
Retrospective Comparative Analysis of Hallux Interphalangeal Joint Fusion Fixation Constructs
Authors: Hyer Christopher , Wakefield Elizabeth , Olson Jessica 
Published: September 2017

Category: Midfoot/Forefoot Introduction/Purpose: Arthrodesis is a common treatment for painful, deformed hallux interphalangeal joints (IPJ). To date, the ideal fusion construct for this treatment is unclear; however, intramedullary screw fixation has been proven a viable construct. The goal of this retrospective comparative analysis was to compare use of a single 4.0-mm intramedullary screw versus two 3.0- mm headless intramedullary screws in fusion rate, average time to fusion, and the rate of other clinical outcomes (e.g. infection, nonunion, delayed union, rate of hardware removal). Methods: Thirty-nine patients underwent hallux IPJ fusion at our institution from 2008 – 2014 that met all inclusion criteria (18 years or older and had hallux IPJ pathology requiring arthrodesis) and no exclusion criteria (concomitant procedures that would affect postoperative weightbearing course, other forms of fixation, and osteomyelitis). Of the 39 patients, 17.9% (n=7) received one intramedullary 4.0-mm screw and 82.1% (n=32) received two 3.0-mm headless intramedullary screws. Complete clinical chart and radiologic exams were reviewed for each patient to determine clinical and radiographic fusions. Results: Overall, 76.9% (n=30) of patients achieved complete radiographic hallux IPJ fusion, 10.3% (n=4) partial fusion and 12.8% nonunion. No statistically significant differences (p<0.05) were observed for complete fusion rate (single: 71.4%; two screws: 78.1%); median time to fusion (single: 36.7 (range: 11.0 – 83.9) weeks; two screws: 13.1 (range: 4.7 – 90.9) weeks); and the rate of other clinical outcomes (hardware removal: 1 (14.3%) from single screw, 6 (18.8%) from two screws; revision hallux IPJ arthrodesis: 1 (14.3%) from single screw, 3 (9.4%) from two screws; and infection: 2 (28.6%) from single screw, 4 (12.5%) from two screws). Conclusion: This is the first study to date comparing outcomes between a single and double intramedullary screws for hallux IPJ arthrodesis. Our finding suggests both fixation constructs are comparable in clinical outcome. Surprisingly, hallux IPJ fusion radiographic rates are lower than similar joint fusions; however, revision rates are low suggesting that clinical fusion rates are still acceptable. Future studies could increase power through larger sample size and could explore barriers to better fusion rates.
The Impact of Ankle Arthritis Treatment on Quality Adjusted Life Years
Authors: Hynes Kelly , Wing Kevin , Younger Alastair , Veljkovic Andrea , Penner Murray , Sutherland Jason 
Published: September 2017

Category: Ankle, Ankle Arthritis Introduction/Purpose: Patients living with end stage ankle arthritis suffer significant disability. They are two standard deviations below population scores for all symptom and function SF-36 sub-scales. In addition, they tend to be younger and still active in the workforce. The economic impact of disability attributable to end0stage ankle arthritis has not been quantified. In the era of cost- effectiveness, policy makers want to see tangible evidence to justify the cost of treatment. One common metric has been quality adjusted life years (QALYs). The purpose of this study is to determine the gain in QALYs attributable to surgical treatment of end- stage arthritis. Methods: This study is based on an existing longitudinal cohort of end stage ankle arthritis patients. The study cohort included 180 subjects (45% female, 55% male) with an average age of 61 years, treated with either ankle arthrodesis or arthroplasty. Patients responses to the SF-36 questionnaire were transformed to SF-6D using SF-6D preference based algorithm licensed software (University of Sheffield, UK) to calculate the health utility value at time of surgical consent and at one year postoperatively. The difference in health utility value was assumed to be the gain in health attributable to end-stage ankle arthritis surgery. Using three theoretical valuations per QALY; $20000, $50000, and $100000, based on previously published cost per QUALY for other orthopedic conditions, we calculated the valuation per QALY for treating ankle arthritis at one year post surgery. Results: The mean pre-surgical health utility value was 0.603, and post-surgically it was 0.690, an average gain in health in one year of 0.087 QALY. This is greater than what is considered the minimally important difference threshold. We then calculated the economic gain at QALY valuations of $20000, $50000, and $100000; at $20000/QALY the cost per QALY is $1740. At $50000 the gain is $4350 cost per QALY, and at $100000 it is $8700 per QALY. Conclusion: From this study cohort, surgically treating end-stage ankle arthritis has a meaningful health benefit for a range of cost per QALYs. Moreover, spending on surgical treatment of end-stage ankle arthritis is cost-effective. These results from this cohort provide valuable empirical insights into treating end-stage ankle arthritis - these findings are meaningful for policy makers faced with resource allocation demands.