bluuebunny/crossref_metadata_2025_split huggingface dataset:
Validity of a Revision Surgery Classification System for Ankle Arthritis Surgery
Authors: Younger Alastair S. , Wong Hubert , Wing Kevin , Penner Murray J. , Daniels Timothy R. , Veljkovic Andrea , Glazebrook Mark A. , Lalonde Karl , Dryden Peter 
Published: October 2016

Category: Ankle Arthritis Introduction/Purpose: Reoperations may be a better way of tracking adverse outcomes than complications. Repeat surgery causes cost to the system, and often indicate failure of the primary procedure resulting in the patient not achieving the expected improvement in pain and function. Understanding the cause of repeat surgery at the primary site may result in design improvements to implants or improvements to fusion techniques resulting in better outcomes in the future. Repeat operations around the primary site may also be relevant to the primary surgery. The COFAS group have designed a reoperation classification system. The purpose of this study was to outline the inter and intra observer reliability of this classification scheme. Methods: To verify the inter- and intra-observer reliability of this new coding system, six fellow ship trained practicing foot and ankle Orthopaedic surgeons were asked to classify 61 repeat surgeries. The six surgeons read the operation reports in random order, and reread the reports 2 weeks later in a different order. Reliability was determined using regression analysis and intraclass correlation coefficients (ICC) were calculated and proportions of agreement. The agreement between pairs of readings (915 for inter observer for the first and second read; 61 readings with 15 comparisons) was determined by seeing how often each observer agreed. This was repeated for the 366 ratings for intra observer readings (61 times 6). Results: The inter-observer reliability test on the first read had a mean intra-class correlation coefficient (ICC) of 0.89, range 0.80 to 0.96. For 61 cases, 45 (74%) observations that were given the same code across all six observers for the first read. The inter-observer reliability test on the second read had a mean ICC of 0.94, range .90 to to 1.0. There were 43 (72%) observations that were the same across all six observers. Of all pairs (915 in total) there was agreement in 804 pairs for the first reading (88%). For the second reading there was agreement in 801 pairs (86%). The observers agreed with themselves in the intra-observer observation 324 times out of 366 paired readings (89% agreement of pairs). Conclusion: The COFAS classification of reoperations for end stage ankle arthritis was reliable. This scheme potentially could be applied to other areas of Orthopaedic surgery and should replace the Claiden Dindo modifications that do not accurately reflect Orthopaedic outcomes. As complications are hard to define and lack consistent terminology (Mercer) reoperations and resource utilization (extra clinic visits, extra days in hospital and extra hours of surgery may be more reliable measures of the negative effects of surgery.
Development of a Novel Small Animal Ankle Arthrodesis Model
Authors: Kadakia Rishin J. , Bariteau Jason T. , Kephart Donald T. , Willet Nick 
Published: October 2016

Category: Basic Sciences/Biologics Introduction/Purpose: Ankle arthrodesis is performed for a variety of ankle joint pathology with the most common being post traumatic arthritis. It is estimated that there are nearly twenty-five thousand ankle fusions performed annually in the United States. Reported complication rates vary between studies and patient population characteristics and comorbidities. Our understanding of the biology of ankle arthrodesis is based largely upon spine fusion and long bone animal models. However, bony healing and infection is greatly influenced by local soft tissue and vascular anatomy, therefore the application of data from these models may not be entirely accurate. There is currently no small animal ankle fusion model. Accordingly, the purpose of this study is to develop a reliable small animal ankle arthrodesis model. Methods: A total of twenty Lewis rats were included in this study. Ankle arthrodesis was performed on one extremity of fourteen rats with the other ankle serving as an internal control. An anterior approach was used to expose the tibiotalar joint. Careful technique was utilized to protect neurovascular structures. After adequate joint exposure, a power burr and sharp curette was used to remove joint cartilage. A .042 kirschner wire was then passed through the calcaneus and through the subtalar and tibiotalar joint. Six rats served as controls and their procedures did not involve any joint cartilage removal. Radiographs were taken immediately postoperatively and at 8 weeks. Bony healing was assessed in a blinded fashion by a board certified foot and ankle orthopaedic surgeon using a grading system based upon assessment of cortical bridging and joint space. Results: Sixteen rats – eleven fusions and five controls - underwent the procedure without any perioperative complications and were included in analysis. Four rats were excluded due to a perioperative complication and/or death. The most common postoperative complication encountered was a wound complication (n=3). Of the eleven rats in the fusion group, six (55%) were determined to be fused radiographically. Two of the five controls were radiographically fused (40%). Conclusion: This study demonstrates preliminary data from a novel small animal ankle arthrodesis model. Fifty-five percent of the rats in the fusion group fused based on radiographic evaluation at eight weeks postoperatively. Further work involves improving upon the surgical technique for fusion in this small animal model to help increase fusion rates, and using CT scans and biomechanical testing to further assess fusion. The development of a small animal ankle fusion model will enhance our understanding of the biology of ankle arthrodesis and allow for development of novel therapies aimed at increasing fusion rates and decreasing complications.
Conservative Sharp Wound Debridement by Nurses in the Outpatient Management of Diabetic Foot Ulcers
Authors: Schumer Ross A. , Guetschow Brian , Ripoli Marissa V. , Tennant Joshua N. , Gardner Sue , Phisitkul Phinit , Femino John 
Published: October 2016

Category: Diabetes Introduction/Purpose: With approximately 29.1 million diabetics in the United States and estimated total annual cost of $245 billion, diabetes and its associated complications continue to be an increasing burden on society. The management of diabetic foot ulcers accounts for a significant portion of those expenses. We propose a safe, efficacious and economically prudent model for the outpatient treatment of uncomplicated diabetic foot ulcers. Methods: Enrolled patients had initial sharp wound debridement by one of two foot and ankle fellowship trained orthopaedic surgeons. Patients were treated with total contact casting and subsequently evaluated every two weeks by nurses who utilized a clinical management algorithm and performed conservative sharp wound debridement (CSWD). Results of healing and complications were recorded. Digital photographs of the ulcers from each clinical encounter were retrospectively reviewed in a blinded fashion by two orthopaedic foot and ankle surgeons and compared to the nursing decisions at the time of treatment. Financial calculations estimated the potential cost savings by having nurses perform CSWD. State boards of nursing were systematically surveyed to assess current policies related to CSWD. Results: Average time to clinical healing was 6.03 weeks. There were no identified complications of CSWD performed by nurses. The sensitivity for the timely identification of wound deterioration was 100%, specificity = 86.49%, PPV = 68.75% and NPV = 100% with an overall accuracy of 89.58%. Thirty-six of 51 (70.59%) state boards of nursing responded to the survey with 33 of 36 (91.67%) defining CSWD as within the nursing scope of practice. The estimated cost savings by having nurses perform CSWD over a 6 week treatment period, with all other factors being equal, was $774.60 per patient. When extrapolated to the estimated number of diabetic foot ulcers annually within the United States, this could approach $1.8 to $2.1 billion in potential annual healthcare savings. Conclusion: CSWD of diabetic foot ulcers and calluses by trained nurses is a safe, effective and fiscally responsible clinical practice supported by greater than 90% of state boards of nursing. Utilizing a clinical decision algorithm, nursing evaluation and appropriate referral of ulcers at risk demonstrated 100% sensitivity and 89.58% accuracy. There were no complications associated with nurses performing conservative sharp debridement. When considering the most recent CDC estimates of 29.1 million diabetics with an 8% annual incidence of DFU, implementation of this clinical model on a national scale could result in approximately $2 billion in annual healthcare savings.
Ankle Joint Pressure Changes in High Tibial and Distal Femoral Osteotomies
Authors: Krause Fabian , Barandun Ariane , Klammer Georg , Zderic Ivan , Gueorguiev Boyko , Schmid Timo 
Published: October 2016

Category: Ankle Arthritis Introduction/Purpose: There is evidence from clinical studies and case reports that realignment of knee deformities for accompanying arthritis by high tibial- (HTO) and distal femoral osteotomies (DFO) inevitably changes the hindfoot alignment and ankle pressure characteristics. Methods: Varus and valgus malalignment of the knee was simulated in 12 fresh-frozen human cadaver full-length legs by removal of 5° bony wedges below and above the knee, respectively. Three hundred Newton, representing half body weight were applied onto the femoral head for static axial compression. Intra-articular high-resolution ankle sensors captured pressure. Testing included four measurements: baseline malalignment (1), 5° (2) and 10° realigning osteotomy (3), and control baseline malalignment (4). For the more common HTO, testing was rerun with the subtalar joint fixed in varus and valgus position. Results: Compared to the baseline measurement the opening HTO of 5° led to a mean center of force (COF) medialization of 0.1 mm and a HTO of 10° to a mean lateralization of 0.5 mm. The closing DFO of 5° and 10° both led to a COF mean medialization of 0.3 mm. No COF migration or change of Pmax was significant. With the subtalar joint fixed in varus position significant lateralizations of the COF was seen for the 5° HTO (2.5 mm) and the 10° HTO (2.9 mm). With the subtalar joint fixed in valgus position the 5° HTO led to a COF lateralization of 1.1 mm (significant) and the 10° to a COF lateralization of 0.9 mm (not significant). Pmax changes were not significant. Conclusion: In this biomechanical study, realignment of coronal plane deformities around the knee by HTO and DFO altered ankle pressure characteristics. The COF migration after HTO was significant, when the subtalar joint was fixed. Clinical relevance When indicating a HTO for medial rather than DFO for lateral knee arthritis or deformities, the impact on ankle pressure characteristics should be considered, particularly when compensatory capacity of the subtalar joint is restricted.
Complications After Resection of Os Trigonum or Posterior Talar Process
Authors: Frigg Arno , Studer Claudia , Maquieira Gerardo Juan J. 
Published: October 2016

Category: Sports Introduction/Purpose: The resection of os trigonum or posterior talar process for posterior ankle impingement is a technically easy and frequent operation. So far, the scientific literature has focused only on the surgical approach and perioperative problems. However, the author has encountered unfavorable followup results (professional athletes had to stop their career), which also other surgeons tell to have encountered. This study aims to describe for the first time this complication rate and possible reasons therefore. Methods: From 3/11 to 7/15 29 patients (17male, 12 female, 32+/-14 years) with 30 feet were operated (22 endoscopic, 8 open resections). Average followup was 27+/-13 months. All charts and pre- and postoperative radiographs were retrospectively evaluated. Patients were grouped into “no complications”, “minor temporary (< 3 months)”, “major follow up (end of athletic career)” complications. The following radiographic parameters were measured referenced on the intersection of the talar radius with the calcaneus (Fig. 1): (1) length of posterior talar process/ os trigonum, (2) length of the calcaneus below the posterior process/os trigonum, (3) length of the uncovered subtalar joint after resection. Results: The major complication rate was 13.3% (4 of 30 feet, 2 os trigonum, 2 posterior talar process): all 4 had symptomatic talar edema and 3 of 4 had symptomatic subtalar osteoarthritis. 1 minor complication (persistent pain for 3 months) was found. The length of the posterior talar process was preoperatively 9.37 +/- 2.89 mm (os trigonum 8.62+/- 2.62 mm) postoperatively 0.64+/-1.8 mm. The length of the posterior calcaneus preoperatively was 8.35 +/- 4.63 mm, postoperatively 1.97 +/-3.0 mm. The uncovered subtalar joint surface postoperatively was 1.77+/- 2.92 mm. All patients with major complications showed retrospectively what we call the “deadly configuration”: the radius of the talus ends within the subtalar joint. Consequently the free subtalar joint surface was significantly larger (6.4 mm +/- 3.33) in feet with major complications than in feet without (1.06 mm +/- 2.15, P < 0.001). Feet without complications but with this deadly configuration (7/26) had a lower free subtalar surface (3.27 mm +/- 1.81, P=0.09) than feet with major complications. Conclusion: The resection of os trigonum or posterior talar process has a high complication rate of 13.3% with symptomatic talar edema and subtalar osteoarthritis at follow up which can be career-ending in professional athletes. The only risk factor found was what we call the “deadly configuration” characterized by the ending of the talar radius into the subtalar joint. In such cases, the resection has to be made sparingly preferably not anterior into the subtalar joint and patients have to be informed about this possible unfavorable course.
Sustained Release of Bone Morphogenetic Protein 2 via Coacervate
Authors: Hogan MaCalus V. , Hicks Justin H. , Engineering Biomedical , Rocha Jorge L. , Li Hongshuai , Wang Yadong , Huard Johnny 
Published: October 2016

Category: Basic Sciences/Biologics Introduction/Purpose: Currently, there is no cure for osteoarthritis (OA) with treatment aimed at symptom relief and improved function. Muscle-derived stem cells (MDSCs) have been shown to exhibit long-term proliferation, high self-renewal, and can undergo chondrogenic differentiation when cultivated in chondrogenic medium in vitro and can differentiate into chondrocytes and repair injured articular cartilage (AC) in vivo. MDSCs retrovirally transduce to express chondrogenic proteins (BMPs) to differentiate into chondrocytes and enhance cartilage repair in vivo. Gene therapy is a promising approach to promote the chondrogenic potentials of MDSCs for AC repair. We have developed a unique sustained growth factor delivery platform comprised of native heparin and a synthetic polycation incorporated with BMP2 (BMP2 coacervate) which can sustain delivery of BMPs to stimulate the chondrogenesis of MDSCs for AC repair. Methods: MDSC were stimulated in vitro with single dose of free BMP2, multi-dose BMP2, BMP2 coacervate, coacervate alone (vehicle only), or in the absence of BMP2 and coacervate (control). BMP2 effects on MDSCs were evaluated by RT-PCR. 20μl of a MIA solution was injected into the knee joint of C57B6 mice to induce osteoarthritic lesions. Two weeks after MIA injection, 20μl of PBS (PBS control), 1×106 MDSCs with 1μg of free BMP2 (MDSC-free BMP), or MDSCs with 1μg BMP2-coacervate (MDSC- BMP coacervate) were injected into the knee joints of the OA injured mice. After 4 weeks, macroscopic and histologic evaluations of cartilage regeneration were conducted. Results: mRNA expression of Aggrecan and Col2A were significantly higher in each BMP2 group compared to control or vehicle only (P < 0.05). Multi-dosage free BMP2 demonstrated significantly higher Aggrecan expression compared to single dose free BMP2 (p < 0.05). Col2A and aggrecan expression in the BMP coacervate group was superior to both single and mult-dose free BMP2 delivery (p < 0.05) (Fig 1A). Histologic examination demonstrated superior cartilage repair and integration in the BMP2 coacervate group (Fig. 1B). Conclusion: This study demonstrates that sustained growth factor delivery (BMP2) is a potential therapeutic option for muscle- derived stem cell based cartilage regeneration for the treatment of osteoarthritis. Prolonged delivery of BMP2 via coacervate led to enhanced MDSC chondrogenesis in vivo and improved cartilage regeneration in vivo. Our results demonstrate an effective method for prolonged exposure to BMP2 and is more clinically translatable.
Early Weight Bearing Following First TMT Arthrodesis
Authors: Bohay Donald R. , Hooper Jessica M. , Anderson John G. , Maskill John D. , Padley Michelle A. , Behrend Lindsey , Rust C. Luke , Beuchel Matthew W. 
Published: October 2016

Category: Midfoot/Forefoot Introduction/Purpose: The modified Lapidus arthrodesis is an accepted method of correcting varying degrees of hallux valgus with or without associated first ray insufficiency. Improved operative techniques have led to more reliable outcomes and lower incidence of nonunion. As a result, the modified Lapidus procedure has increased in popularity. Historically, surgeons have followed cautious postoperative protocols, initially restricting weight bearing until bone consolidation is confirmed radiographically. More recently, an alternative approach to postoperative management has been proposed, allowing patients to bear weight as tolerated two weeks after surgery with the goal of improving patient compliance while minimizing postoperative disability. The purpose of this study is to compare outcomes of patients randomized to either early weight bearing or standard non-weight bearing postoperative course following modified Lapidus arthrodesis. Methods: We determined that at least 130 patients would need to be enrolled in this study to achieve statistical significance (p < 0.05). Beginning in 2012, patients with hallux valgus indicated for modified Lapidus arthrodesis were assigned to either the investigational Group A (early weight bearing) or to the control Group B (standard of care) by a random number generator. All patients underwent modified Lapidus arthrodesis by one of the three senior authors (JGA, DRB, JDM). Specific demographic, clinical, patient-centered, and radiographic data were collected during the preoperative visit, the operative procedure, and at defined intervals during the postoperative period. The primary outcome variable was defined as first tarsometatarsal joint fusion at six months. Results: To date, 100 subjects have been enrolled, 57 of whom (40 patients in Group A, 17 patients in Group B) have completed one year of follow up. At six months, 38/40 patients in Group A had achieved radiographic union, compared to 17/17 patients in Group B (p = 0.495). Smoking status, BMI, and age at surgery were not found to be significantly associated with rate of union in either group. Patients in Group A required less time to reach full weight bearing status (p < 0.001). At six weeks after surgery, Group A reported significantly higher levels of physical function and overall composite scores on the SF-36 questionnaire. The rate of adverse events was not significantly different between the two groups at any postoperative timepoint. Conclusion: Though data collection is ongoing, our results indicate that clinical, patient-centered, and radiographic outcomes were comparable following modified Lapidus arthrodesis in both the early weight bearing and standard of care patient groups. Early weight bearing does not appear to increase the rate of adverse events or significantly slow rate of fusion, and also reduces postoperative disability.
Two-Year-Followup in 20 Patients After Matrix-Associated Stem Cell Transplantation (MAST) in Chondral Defects of the 1st Metatarsophalangeal Joint
Authors: Richter Martinus , Zech Stefan , Meissner Stefan A. 
Published: October 2016

Category: Other Introduction/Purpose: For treatment of chondral defects, matrix-associated stem cell transplantation (MAST) is a modification of autologous matrix-induced chondrogenesis (AMIC) with a potential higher concentration of stem cells due to harvesting fluid at the bone marrow and in-vitro processing. The aim of the study was to assess the 2-year-followup of MAST in chondral defects of the 1st MTP. Methods: In a prospective consecutive non-controlled clinical follow-up study, all patients with chondral defect that were treated with MAST from April 1st 2009 to March, 30th, 2013 were analyzed. Patients with bilateral treatment or with MAST at more than one joint surface were excluded from the study. The size and location of the chondral defects, method-associated problems and the Visual-Analogue-Scale Foot and Ankle (VAS FA) and range of motion were registered and analyzed. MAST was performed as a single open procedure including debridement and microfracturing of the chondral defects. Stem cell- rich blood was harvested during the procedure from the ipsilateral pelvic bone marrow and was centrifuged (10 minutes, 1,500 RPM). The supernatant was used to impregnate a collagen I/III matrix (Chondro-Guide®, Geistlich, Baden-Baden, Germany) that was cut to the size of the defect before. The matrix with stem cells was fixed into the chondral defect with fibrin glue (Tissucoll, Deerfield, USA). Results: Twenty-five chondral defects in 20 patients were included in the study. The age of the patients was 42 years on average (range, 35-62 years), 14 (70%) were male. The VAS FA before surgery was 50.5 on average (range, 18.3-78.4). The defects were located as follows, medial metatarsal head, n=7; lateral metatarsal head, n=18 (medial and lateral metatarsal head, n=5). The defect size was 0.7 cm2 on average (range, .4 - 1.5 cm2). ROM was 10.2/0/18.8° on average. All patients completed 2-year- followup. No method related complications were registered. The VAS FA improved to an average of 91.5 (range, 74.2-100; t-test (comparison with preoperative scores), p=.01). ROM improve to 32.5/0/25.5 one average (p=.05). Conclusion: MAST led to good clinical scores and improved range of motion. No complications were registered. Even though a control group is missing, we conclude that MAST is a safe and effective method for the treatment of chondral defects of the 1st MTP joint. The main advantage of MAST in comparison with ACI and MACI is the single procedure methodology. The advantage in comparison with AMIC is the potential higher concentration of stem cells. It remains unclear if this method is superior to AMIC, and what kind of tissue is created.