bluuebunny/crossref_metadata_2025_split huggingface dataset:
New Technique for Measuring Limb Occlusion Pressure Facilitates Personalized Tourniquet Systems
Authors: Younger Alastair S. , Jeyasurya Jeswin , McEwen James , Masri Bassam , Day Brian 
Published: October 2016

Category: Basic Sciences/Biologics Introduction/Purpose: Optimal tourniquet safety depends on accurately determining the minimum pressure necessary to achieve a bloodless surgical field, known as a patient’s limb occlusion pressure (LOP). However, LOP is not yet routinely measured in all patients due to limitations of current techniques. We have evaluated a novel technique for measuring the LOP through the tourniquet cuff that overcomes many limitations of current LOP measurement techniques. Methods: The new technique of measuring LOP involves the use of unique dual-purpose disposable tourniquet cuffs along with a tourniquet instrument containing LOP calculation sensors and software. A randomized crossover multicenter trial with 143 pre-surgical or post-surgical patients enrolled in the study. Pneumatic cuffs were applied to the non-operative upper and lower limbs and LOP was measured using the new technique and the Doppler ultrasound technique. For each patient a set of four LOP measurements was taken, using the new technique (experimental) and the Doppler technique (control) on one upper and one lower limb. Blinding was achieved during LOP measurement by using two experimenters and blinding the experimenter who measured the LOP using Doppler ultrasound from the LOP reading using the new automatic technique. Participants were blinded from all LOP measurement results by keeping the displays of measurement equipment out of their view. Results: The differences between the new technique and Doppler technique were neither statistically nor clinically significant and the new technique is as robust as the Doppler technique. The results of this study can be used to develop personalized tourniquet systems consisting of unique dual-purpose cuffs connected to instruments suitable for measuring tourniquet LOP with the new measurement technique. The simplicity, effectiveness, and accuracy of this technique should lead to broader clinical usage and acceptance of LOP measurement, thus leading to safer, personalized pressures in surgical tourniquet applications. Conclusion: The new technique is equally robust as the Doppler technique. Both techniques worked successfully in the 252 limbs from which usable data was collected. Of the 34 limbs for which there were data collection errors or exclusion, only two measurements were excluded because of an instrument error using the automatic technique compared to one measurement excluded because of a Doppler technique measurement error.
Dynamic Ultrasonography During Nonoperative Treatment following Achilles Tendon Rupture
Authors: Lee Kang 
Published: October 2016

Category: Ankle Introduction/Purpose: Many recent studies suggest similar outcome and rerupture rates between operative and nonoperative treatment with accelerated rehabilitation for acute Achilles tendon rupture. Nevertheless, it is very difficult for surgeons who have traditionally been performing surgery for Achilles tendon rupture to adopt nonoperative treatment. Unlike fracture healing, surgeons cannot confirm the amount of tendon healing with plain radiography to begin accelerated rehabilitation. The aim of the present study was to determine visually the amount of Achilles tendon healing with dynamic ultrasonography and therefore aid in surgeons decision-making process during nonoperative treatment following Achilles tendon rupture. Methods: Thirty-one patients with acute Achilles rupture were included in the study. The mean age at the time of rupture was 42 years. There were 32 male and 10 females. Ultrasonographic evaluation was performed at the time of initial diagnosis, and at 2, 3, 5, 7, 10, 13 weeks after injury. Initially the amount of gap with ankle in neutral position was measured, then the amount of tendon healing(continuity) was measured during the follow-up. Results: Initially, the mean gap was 13 mm with ankle neutral, then the mean gap was reduced to 3 mm with maximum ankle plantarflexion. At 3 weeks, proximal stump motion was confirmed with mean gap of less than 2 mm during passive ankle motion from maximum plantarflexion to neutral in all patients, indicating that tendon healing began between the distal and proximal stumps. Yet, there were no definitely visible continuity between the two stumps. At 5 weeks, 30% of entire tendon width showed continuity, 50% at 7 weeks, 70% at 10 weeks, and the entire tendon healed at 13 weeks. Clinically, all patients returned to previous activities of daily living without any complications at the final follow-up. Conclusion: Surgeons beginning to adopt nonoperative treatment for acute Achilles tendon rupture may safely remove the cast or orthosis at three weeks after injury for gradual increase in ankle range of motion and to reduce patient disability.
Anatomical Features of Dislocation of the Peroneal Tendon
Authors: Taki Masanori , Hasegawa Atsushi , Monden Satoshi , Hio Naohiro 
Published: October 2016

Category: Ankle Introduction/Purpose: Dislocation of the peroneal tendons is one of the major injuries of the ankle. However, the pathology underlying this condition is still unclear. The purpose of this study was to evaluate the anatomical features of dislocation of the peroneal tendon using MRI. Methods: We compared twenty cases of dislocation of the peroneal tendon and twenty three controls. Both groups were matched for age, gender and BMI. The following patients were excluded: those with an acute injury within the past three weeks and/or findings of peroneal tendon tears or a dislocated peroneal tendon on MRI. MRI axial images of the ankle were retrospectively observed and the shape (concave, convex or flat) of the posterior fibular malleolar groove and the soft tissue dimensions within the peroneal tendon sheath at the level of the ankle joint (joint level) and the middle level between the ankle joint and the fibular malleolar tip (lower level) were investigated. The measurement was performed using a Konica i-pacs SX measurement system (Konica Minolta Health Care, Tokyo, Japan). Results: No significant differences were observed in the shape of the posterior fibular malleolar groove at both levels (Joint level, peroneal dislocation: concave, convex, flat = 2, 10, 8 cases vs. control: 4, 12, 7 cases. P=0.70. Lower level, peroneal dislocation: concave, convex, flat = 3, 6, 11 cases vs. control: 6, 6, 11 cases. P=0.36, Chi-square test for independence). However, a significant difference was confirmed in the soft tissue dimensions within the peroneal tendon sheath (Joint level, peroneal dislocation: 144.6±41.4mm2 vs. control: 97.5±29.1mm2. P < 0.0001. Lower level, peroneal dislocation: 120.2±36.1mm2 vs. control: 84.3±26.8mm2. P < 0.0001, Student's t-test). Conclusion: These results suggest that a larger amount of soft tissue inside of the peroneal tendon sheath at the level of the distal fibula is a significant anatomical feature associated with peroneal tendon dislocation, and could be a potential risk factor for unstable peroneal tendons. It remains unclear whether the soft tissue was bulky prior to injury. However, the presence of enlarged soft tissue within the peroneal tendon sheath is considered to be involved in the pathology of recurrent dislocation of the peroneal tendon.
Evaluation of Normal Ankle Cartilage by Magnetic Resonance Imaging (MRI) T1ρ Mapping
Authors: Katsui Ryuhei , Taniguchi Akira , Ogawa Munehiro , Tanaka Yasuhito , Kurokawa Hiroaki , Tomiwa Kiyonori 
Published: October 2016

Category: Ankle Introduction/Purpose: With the recent remarkable progresses in image diagnosis using magnetic resonance imaging (MRI), it could be possible to evaluate articular cartilage in detail. T1ρ mapping by MRI has recently drawn attention as a noninvasive cartilage evaluation method. While its validity has been proven, there are no reports describing T1ρ mapping for the ankle; therefore, in this present study, T1ρ values of the articular cartilage surfaces of the talar dome were measured in healthy individuals. Methods: The study sample comprised 10 ankles from 10 healthy volunteers (4 male and 6 female), with a mean age of 32.2 years. Images taken using a 3.0 T MRI device, manufactured by Philips, were processed using the PRIDE software (Philips, Inc.) and analyzed using Image J, a specialized analysis software. Evaluations were performed using slices in the coronal plane from the trochlear ridge of the talus and slices 10 mm anterior and posterior of the ridge. Each slice was divided into three equal parts including the medial, central, and lateral areas of cartilage on the articular surface of the trochlea tali, to totally yield 9 regions of interests where T1ρ values (ms) were measured. Furthermore, values were measured thrice for each region in each volunteer, and the mean was calculated. Results: T1ρ values for the medial, central, and lateral regions were 31.0 ± 6.4 ms, 31.2 ±7 .2 ms, and 32.2 ± 6.9 ms, respectively for the anterior talus; 24.2 ± 4.2 ms, 21.7 ± 5.6 ms, and 25.1 ± 5.5 ms, respectively for the trochlear ridge of the talus; and 33.8 ± 4.8 ms, 31.9 ± 4.5 ms, and 35.1 ± 4.8 ms, respectively for the posterior talus. T1ρ values were significantly lower in the anterior and posterior areas of the talar dome than in the trochlear ridge of the talus (p < 0.05). Conclusion: Proteoglycan content of articular cartilage in the talar dome was determined to be low in the anterior and posterior areas, that reveals load application might be concentrate on these areas.
Interest of Tantalum for Arthrodesis-Reconstruction of TAR Revision
Authors: Besse Jean-Luc , Aubret Syvain , Lomberget-Daubie Marie-Caroline , Fessy Michel-Henry 
Published: October 2016

Category: Ankle Arthritis Introduction/Purpose: Ten-year Total Ankle Replacement (TAR) survivorship improved from 80 to 90%. But periprosthetic osteolysis associated with implant subsidence remains the main problem, with difficult revision surgery by arthrodesis; bone defect requiring massive graft. We proposed an original approach using porous tantalum as spacer to fill the defect and reinforce arthrodesis-reconstruction Methods: From October 2013 to September 2015, eleven patients underwent TAR revision (7 AES TM, 2 Hintegra TM, 1 Salto TM, 1 Albatros TM) by ten TTC arthrodesis and one ankle arthrodesis using tantalum (with Zimmer Trabecular Metal Ankle Interpositional SpacerTM introduced in July 2013). All patients were followed up prospectively clinically and radiologically (X-rays and CT scan at 4-6 months, and 1 year); and a bone scan with SPECT- CT if residual pain at one year. Mean age was 53.2 yrs [37-82yrs] at TAR, 66.6 yrs [41–90 yrs] at revision-arthrodesis, with a mean interval of 7.2 yrs [2-12yrs]. Results: We used a tantalum cone (25-40 mm height) and osteosynthesis by a retrograde nail in 10 TTC arthrodesis cases (Tornier–AFN611TM, 10 or 12 mm diameter, 6° or 11° lateral angulation) associated or not to a complementary anterior sub- talar screw (Unima-BiotechTM 4.5 mm), and a double anterior plate in one ankle arthrodesis case . Tantalum implants were surrounded by antologous bone graft (1 posterior iliac crest, 10 iliac wing harvested with hip reamers) mixed with Lyophylized fragmented Human Bone. Postoperatively, patients were 6 weeks without weight-bearing, followed by 2 months of boot with weight-bearing. At a mean 1 year follow-up (4 -18 mo), ankle fusion was confirmed on CT in all cases but with doubt for 2 cases. But there remained three case of unexplained residual severe pain associated with hyperactivity on bone scan: incomplete fusion (difficult to assess on CT due to tantalum)? impingement between locking-screws and Tantalum? Conclusion: Porous tantalum had biological and biomechanical properties close to those of natural bone. The use of Trabecular MetalTM in hip, knee, spine surgery recently demonstrated efficacy; but there are few recent publications in TAR revision. Our preliminary results are encouraging; tantalum allows primary stability of reconstruction. Is it better than Titanium cages? We need longer follow-up to analyze integration and fusion; and to check the residual pain in some cases.
Interobsever Variability of Measurements for Flatfoot Deformity Using High Resolution Weightbearing Cone-Beam CT Examination According to Reader Experience
Authors: Netto Cesar Cesar , Demehri Shadpour , Dein Eric J. , Zhang Hanci , Thawait Gaurav K. , Zahoor Talal A. , Fonseca Lucas F. , Lee Moses , Asomugha Eva U. , Ficke James R. , Schon Lew C. 
Published: October 2016

Category: Other Introduction/Purpose: To evaluate interobserver reliability among readers of different clinical experience by applying measurements for adult acquired flatfoot deformity (AAFD) using high-resolution three-dimensional (3D) weightbearing (WB) cone-beam CT (CBCT) examination. Methods: In this IRB approved study, 20 patients with flexible AAFD [12 male, 8 female; mean age 54.2 (20-88) years] were scanned with standing (weightbearing) CTs. Two blinded observers, a medical student and a foot/ankle surgeon, applied validated AAFD measurements in sagittal, coronal, and axial planes using predefined anatomical landmarks. Interobserver reliability was calculated using Pearson correlation. Results: There was significant interobserver agreement with high correlation for the following measurements(p < 0.0001): distances between medial cuneiform to-floor (r=0.981) and to-skin (r=0.986), navicular to-floor (0.992) and to-skin (r=0.900); cuboid to-floor (r=0.975) and to-skin (r=0.978), and calcaneus-to-fibula (r=0.808); calcaneal inclination angle (r=0.795); forefoot arch angle (r=0.983); and subtalar horizontal angles at 25%, 50%, and 75% of the anteroposterior joint length (r=0.784, 0.891, 0.809). Significant agreement with moderate correlation was additionally demonstrated for talar-first metatarsal angle (r=0.553, p < 0.014), medial cuneiform-first metatarsal angle (r=0.668, p < 0.001), and navicular-cuneiform angle (r=0.746, p < 0.0002). Level of training did not influence the reliability of any measurements except medial cuneiform-first metatarsal angle (specialist: 8.83°; student: 1.61°; p < 0.01). Statistically insignificant difference between readers (p>0.05) was noted in mean talar-first metatarsal and subtalar horizontal angles. Conclusion: While literature describes large variability for AAFD measurements from plain radiographs among readers of varying medical experience, 3D WB CBCT can yield similar measurements using predefined planes with high reliability, independent of reader experience.
Results of Augmented Half-Thickness Tibialis Anterior Tendon Segment Transposition, a Novel Technique for Tibialis Anterior Tendon Reconstruction
Authors: Stenson James F. , Reb Christopher W. , Pedowitz David I. , Daniel Joseph N. 
Published: October 2016

Category: Ankle Introduction/Purpose: Tibialis anterior tendon (TAT) rupture causes substantial morbidity. Nearly 200 surgical cases have been reported in the literature since 1905 wherein primary repair was not achieved approximately 40% of the time due to post- debridement tendon defect size. The present study describes the clinical outcomes of augmented, half-thickness TAT segment transposition, a novel reconstruction technique for managing post-debridement TAT defect. The purpose was to assess this technique as an alternative to tendon transfer and allograft tendon interposition. Methods: IRB-approved, retrospective electronic medical record review of patients with attritional distal TAT rupture. In all cases, the post-debridement tendon defect prohibited primary repair or reinsertion and was managed by distal transposition of a half-thickness TAT segment to span the defect. This graft was secured with a six core suture end-to-end anastomosis. Then, this repair was augmented with human acellular dermal matrix allograft (Graftjacket®, Wright Medical Technology, Memphis, TN). A total of five patients were treated with this technique. One patient died of unrelated causes remote from surgery and one was lost to follow up. Three patients with a minimum one year follow up were included. Outcomes were assessed via observed range of motion, clinical motor power assessment, ability to heel walk 15 feet, visual analog scale pain score, Foot and Ankle Ability Measure score, postoperative complications, and patient satisfaction at one year. Outcomes data were analyzed using descriptive statistics. Results: The mean age was 68 years (range, 59 to 73 years). Two patients were female. Mean interval between injury and surgery was 59.3 days (range, 15 to 146 days). All patients regained symmetrical range of motion, medical research council grade 5 motor power and the ability to heel walk. Mean pain scores improved from 4.6 (range, 2.5 to 8.5) preoperatively to 0.7 (range, 0 to 2) postoperatively. Mean FAAM scores increased from 30.6 (range, 23.8 to 43.8) preoperatively to 78.7 (range, 72.6 to 97.6) postoperatively. No postoperative complications occurred. At one year, one patient was satisfied and two were very satisfied with their outcome. Conclusion: Although constrained by a small sample size, the present findings appear to indicate that this technique produces short term clinical results comparable to those described for other techniques for TAT reconstruction. Future work should assess if these results are reproducible and long lasting. Additionally, the relative value of saving donor site morbidity or the cost of allograft tendon in comparison to the added cost of the Graftjacket should be determined
Single-Stage Bipedicle Local Tissue Transfer and Skin Graft for Achilles Tendon and Posterior Heel Wound Complications
Authors: Dekker Travis J. , Matson Andrew P. , Mithani Suhail K. , Adams Samuel B. 
Published: October 2016

Category: Ankle Introduction/Purpose: Achilles tendon and posterior heel wound complications are difficult to treat. These typically require soft tissue coverage via microvascular free tissue transfer at a tertiary referral center. Here we describe coverage of a series of posterior heel and achilles wounds via simple, local tissue transfer, a bipedicle fasciocutaneous flap. This surgical technique can be performed by an orthopaedic foot and ankle surgeon without resources of tertiary/specialized care or microvascular support. Methods: Three patients with separate pathologies were treated with a single-stage bipedicle fasciocutaneous local tissue transfer. Case 1 was a patient with wound breakdown following midsubstance Achilles tendon repair. Case 2 was a patient with insertional wound breakdown after Achilles debridement and repair to the calcaneus. Case 3 was a heel venous stasis ulcer with calcaneal exposure in a diabetic vasculopath. All three cases were treated with the following technique: an incision was immediately posterior to the lateral malleolus. The length of the incision was approximately 25% greater than the proximal to distal measurement of the wound. The dissection was carried to the flexor retinaculum and carried posteriorly to create a fasciocutaneous flap attached proximally and distally. This flap was then mobilized posteriorly to close the desired defect, leaving an ellipsoid shaped skin defect laterally. A split thickness skin graft was used to cover the defect created by the flap transposition. Results: All three patients demonstrated initial complete healing of the posterior defect, lateral ankle skin graft recipient site, and the skin graft donor site following surgery. Case 3 had a subsequent recurrent ulceration after initial healing. This was superficial and healed with local wound care. All patients regained full preoperative range of motion and were able to ambulate independently without modified footwear. Conclusion: The bipedicled fasciocutaneous flap described offers a simple, predictable single stage procedure that can be accomplished by an orthopaedic foot and ankle surgeon without resources of a tertiary care center for posterior foot and ankle defects. This flap allows for relatively short operative times and can be customized to facilitate defect coverage. Ultimately, the flap is sufficiently durable to withstand the local tissue stresses required for ambulation at an early stage. This provides a reasonable alternative to complicated and time consuming microvascular reconstruction, but does require careful follow-up to manage the patient’s underlying comorbid conditions that may complicate wound healing.
The Biomechanical Evaluation of Revision First Metatarsophalangeal Arthrodesis
Authors: Aiyer Amiethab , Myerson Mark S. , Dall Graham , Price Jamey , Widmer Jason 
Published: October 2016

Category: Midfoot/Forefoot Introduction/Purpose: First metatarsophalangeal (MP) arthrodesis in the setting of bone loss is a difficult problem. Bone loss may compromise stability of implant fixation. Union rates may be adversely affected by these circumstances. The primary goals of this cadaveric, biomechanical study were as follows: 1) To investigate stiffness of a dual mini-plate construct versus a standard MP arthrodesis plate in the setting of severe bone loss, 2) To evaluate arthrodesis interface motion when an interpositional graft is used. Methods: Twelve matched pairs of fresh, frozen cadaveric foot/ankle specimens were utilized in this study. Pairs were randomized to fixation constructs via computerized randomization (Excel, Microsoft, WA). Within a matched pair one construct used the dual mini plate fixation technique while the other was secured with a standard MP arthrodesis plate. (Fig 1) A revision MP fusion construct with structural bone graft was simulated on six of the specimen pairs, while the remaining constructs did not utilize any interpositional graft. Results: Based on load to failure data, there were no differences between the various constructs in terms of stiffness. There was a high degree of calculated plantar gapping with the placement of a bone block, irrespective of the fixation type. In the presence of an interpositional graft, regardless of plating construct, the calculated proximal interface strain was an average of 26%. Subsequently, failure was most commonly seen at the proximal interface of the interpositional graft group (83%, 10 out of 12). Distal interface strain in the interpositional graft group was calculated to be 11%. The proximal interface strain was significantly larger than the distal interface strain (26% vs 11%) (p < 0.05). Conclusion: Although no construct differences were observed in terms of stiffness, the dual mini-plate is an alternative option for fixation when asymmetric bone loss is either seen on the phalangeal or metatarsal head side. The high degree of plantar gapping of the proximal interface with the placement of the bone block may have implications for healing potential across the arthrodesis site.