bluuebunny/crossref_metadata_2025_split huggingface dataset:
Muscular Vein Thrombosis Previous to Immobilization in Acute Tendo Achilles Rupture
Authors: Lopez Valeria , Slullitel Gaston , Ortiz Cristian , Wagner Emilio , Pinton Gustavo Norberto , Alvarez Victoria 
Published: September 2017

Category: Ankle Introduction/Purpose: Thromboembolic complications during lower-limb immobilization after Achilles tendon ruptures are common. Both operative and nonoperative treatments of Achilles rupture include a period of immobilization which is a well- documented risk factor for distal vein thrombosis. Curiously, there is a gap in literature linking the diagnosis of thromboembolic events to the Achilles rupture previous to the inmobilization. The term DTV refers to the anterior/posterior tibial or the peroneal veins, i.e. those that correspond to arterial structures and comprise the profound vein system. Although still with little agreement, the role of muscular vein thrombosis or isolated gastrocnemius or soleus vein thrombosis are gaining relevance within the current published data, despite there is no report of it association with tendo Achilles rupture before or after the initiation of treatment. Methods: Case report: Five consecutive patients with a diagnosis of traumatic Achilles rupture were evaluated. All patients sustained non traumatic injuries. One of the patients was a heavy smoker, and two of them had BMI over 25. We routinely execute an ultrasound to locate the rupture site and at the same time color ultrasound Doppler was performed by an expert in vascular echography, before the initiation of treatment. In all cases a thrombosis of the calf muscle veins was found. Surgical treatment was not advice in any of the patients and definitive treatment was conservative. Results: Calf muscle veins are deep veins in the distal lower extremity that are nonpaired and not associated with named tibial arteries. These veins make up a complex venous system of the musculature of the posterior leg and include the soleal and gastrocnemius veins that run as sinusoids within the muscles of the same name. The soleal sinusoids may drain into the midperoneal or posterior tibial veins, whereas the gastrocnemius sinusoids may empty directly into the popliteal vein. Although the real incidence of MVT is extremely variable, in patients presenting with symptoms and signs suspicious for distal vein thrombosis, muscular veins have been shown to be the most common location for thrombosis with 23% to 41% of all patients. Conclusion: Our group of patients was diagnosed before immobilization was established. One plausible explanation could be that the muscle trauma associated with the tendinous rupture may have some influence in the thrombi generation triggering endothelial dysfunction, or affecting the calf muscle pump creating venous stasis, conditions that favour the VTE appearance. It is our perspective that although not well stablished there is at least a theoretical risk of further propagation to the profound venous system and subsequently to the pulmonary system, and this fact not only conditions the treatment of MVT itself, but also the treatment of the Achilles rupture.
Remodeling of the Calcaneocuboid Joint in the Flatfoot
Authors: Manoli Arthur 
Published: September 2017

Category: Hindfoot Introduction/Purpose: Although the flatfoot has been successfully treated with a lateral column lengthening (LCL) for over half of a century, there has been controversy recently about whether the lateral column is actually short in a flatfoot, especially the acquired type. Some ask, “How can the normal, hard bones actually change and shorten?” And, if it is not short, perhaps the lengthening procedure is producing a non-physiologic state with abnormal anatomy. Would the flatfoot patient be better served with other procedures that don’t include a lateral column lengthening? Level of Evidence: Therapeutic Level IV. Methods: After observing a very dramatically changed calcaneocuboid (CC) joint when performing a double calcaneal osteotomy with a medial soft tissue reconstruction for a Johnson-Strom Stage II posterior tibial tendon insufficiency, it was decided to carefully observe, photograph, and record any changes in the CC joint at surgery in a consecutive series of 21 patients who were operated on who had this disorder(Figure 1). In total, there were fourteen double heel osteotomies, with medial soft tissue reconstructions for Johnson-Strom Stage II deformities, five triple arthrodeses for Stage III deformities, and two lateral column lengthenings with an ankle arthrodesis for a Stage IV deformity. All of the patients had a triple hemisection heel cord lengthening for hindfoot equinus. Results: Every patient studied had some changes to the CC joint which were generally related to the amount of deformity present. At a minimum, the calcaneal side of the joint drifted proximally, laterally and dorsally, with bone being laid down on the outside of the calcaneus, resulting in the joint being larger. There was drifting and abduction of the lateral portion of the articular surface of the joint. In some joints the lateral portion looked like a distinct but confluent facet. Often times, a marginal osteophyte was present laterally and dorsally in the widened area of the calcaneus and “kissing” osteophytes were seen on the cuboid. All of these remodeling changes resulted in the calcaneal side of the joint being short, and facing laterally and dorsally. Conclusion: These findings give evidence to the rationale for performing of a LCL proximal to the calcaneocuboid joint to treat the acquired flatfoot. When performing a LCL one should attempt to restore length to the calcaneal side of the joint, and to redirect it medially and plantarward. We do not remove the marginal spurs, rather they are maintained to provide an area to insert a retrograde fixation screw. If the patient has lateral column pain after the bone graft has incorporated, the screw and spurs are removed.
Biphasic Bioresorbable Scaffold (TruFit Plug®) for the Treatment of Osteochondral Lesions of Talus
Authors: Marcellini Lorenzo , Cave Elvira Di , Versari Pierluigi , Luzon David 
Published: September 2017

Category: Ankle, Ankle Arthritis Introduction/Purpose: The ideal treatment of osteochondral lesions of the talus (OLT) is debatable. The TruFit plug has been investigated as a potential treatment method for osteochondral defects. This is a biphasic scaffold designed to stimulate cartilage and subchondral bone formation. The purpose of this retrospective study was to investigate the long-term functional and MRI outcomes of the TruFit Plug for the treatment of OLT. Methods: We evaluated 12 consecutive patients treated from March 2007 to April 2009 for OLT. Clinical examination included the American Orthopaedic Foot and Ankle Society (AOFAS) ankle score and the visual analog scale (VAS) for pain. MRI scans were optained pre-treatment and at last follow-up. The Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score was used to assess cartilage incorporation. Results: Mean follow-up was 7.5 years (range, 6.5 to 8.7 years). The average age was of 38.6 years (range, 22 to 57 years). The sex ratio between males and females was 3:1 (9 males, 3 females). The mean AOFAS score improved from a preoperative score of 47.2 ± 10.7 to 84.4 ± 8 (p< 0.05). According to the postoperative AOFAS scores 1 case obtained excellent results, 9 were classified as good, and 2 were fair. VAS score improved from a preoperative value of 6.9 ± 1.4 points to 1.2 ± 1.1 points at last follow-up (p< 0.05). The MOCART score for cartilage repair tissue on postoperative MRI averaged 61.1 points (range, 25-85 points). Conclusion: The long-term results suggest that the technique of Trufit Plug for OLT is safely and demonstrates good post- operative scores including improvement of pain and function, with discordant MRI results. However, randomized controlled clinical trials comparing TruFit Plug with an established treatment method are needed to improve synthetic biphasic implants as therapy for osteochondral lesions.
Cross Sectional Area of the Achilles Tendon in a Prospective Cohort of an Elite Military Population
Authors: Martin Kevin , Dawson Laura , Wake Jeffrey 
Published: September 2017

Category: Ankle, Hindfoot Introduction/Purpose: The prevalence of Achilles tendon pathology is common in many sports and daily activities. From ruptures to overuse injuries resulting in tendonopathies, AT dysfunction can result in disability and reduced productively. Continued research that increases our knowledge base of normal Achilles tendon properties can improve our ability to reduce and prevent future AT injuries. In this study, we examined the cross-sectional area (CSA) of the Achilles tendon (AT) at multiple levels in an asymptomatic population of elite American military service members that participate in greater than 20 hours of intense training per week. Methods: We conducted a prospective cohort study composed of 41 active duty United States Army Rangers. The Rangers are a specialized infantry organization that participates in extensive military training and rigorous combat missions. The service members were voluntarily recruited to participate while deployed in a combat theater. All subjects were members of the Ranger Regiment participating in greater than 20 hours of intense bipedal non-sport weekly training with no history of AT pathology. In a standing position, each subject had bilateral Achilles insertion marked along with additional skin markings made at 2 cm, 4 cm, and 6 cm above the AT insertion. At all four levels, the AT was measured in the coronal and sagittal plains using ultrasound. Results: In 41 subjects, a total of 82 Achilles tendons were examined. The mean age of the cohort was 26 years, 70 inches tall, with a mean weight of 187 pounds. The mean sagittal thickness of the AT at the insertion was 4.3 mm, 2 cm above the insertion is was 4.3 mm, 4 cm above the insertion is was 4.2 mm, and at 6 cm above the insertion it was 4 mm. In the coronal plain was 19.1 mm, 14.3 mm, 13.5 mm, and 14.4 mm respectively. The cross-sectional area was calculated at each respective level: 0.65 cm2, 0.48 cm2, 0.44 cm2 and 0.45 cm2. The non-dominant ankle was slightly larger at each level but was not found to be statistically significant. Conclusion: These results provide the mean sagittal and coronal diameters of the Achilles tendon as measured by ultrasound throughout the watershed area of a young active adult male population. Our data also suggest that increased non-sport activity may not increase the cross-sectional area of the Achilles tendon. Identifying the normal diameter at multiple levels throughout the most commonly injured area can potentially improve the provider’s ability to identify early disease processes and apply targeted interventions to help slow or prevent progression and possible rupture.
MOCART Score is Not a Feasible Tool for the Assessment of Osteochondral Lesions of the Talus
Authors: Martinelli Nicoló , Albano Domenico , Prati Alberto Bianchi Castagnone , Antonino Giacalone , Malerba Francesco , Sconfienza Luca 
Published: September 2017

Category: Ankle, Sports, Radiographic assessment Introduction/Purpose: To evaluate the applicability and reproducibility of the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score for morphological evaluation of osteochondral lesions of the talus (OLT) repaired using the autologous matrix-induced chondrogenesis (AMIC) technique. Methods: Two radiologists (R1-R2) and two orthopaedic surgeons (O1-O2) independently reviewed 26 MRI scans of the ankle performed on 13 patients (6 females, 7 males; age: 38.9±15.9, range 14-63) with OLT repaired using the AMIC technique between November 2011 and July 2015 at our institution. Out of 13, 7 were treated with biomimetic osteochondral scaffold implantation, while 6 were treated with bone-marrow derived cell transplantation. The MRI scans were performed at 6 and 12 months after treatment. For inter- and intra-observer agreement evaluation for each variable of the MOCART score we used Cohen’s kappa coefficient. Progression of MOCART score between 6 and 12 months evaluation was assessed using the Wilcoxon test. Results: The inter-observer agreement between R1-R2 ranged from poor (adhesions, k=0.124) to almost perfect (subchondral bone, k=0.866), while between O1-O2 ranged from absent (effusion, k=-0.190) to poor (surface, k=0.172). The intra-observer agreement of R1 ranged from poor (signal intensity, k=0.031) to substantial (subchondral lamina, k=0.677), while that of O1 ranged from absent (subchondral bone, k=-0.061) to substantial (surface, k=0.663). There was a statistically significant increase of MOCART score between 6-month and 12-month evaluation of R1 (Z=-2.672; P=0.008), R2 (Z=-2.721; P=0.007) and O1 (Z=- 3.034; P=0.002). Conversely, the increase of MOCART score between the 6-months and 12-months evaluation of O2 was not statistically significant (Z=-1.665; P=0.096). Conclusion: MRI certainly has a crucial role in the follow-up of surgical repaired OLT but the MOCART score does not seem to be sufficiently reliable and reproducible to be applied for this purpose.
Influence of Depression and Anxiety on Hallux Valgus Surgical Outcomes
Authors: McDonald Elizabeth , Shakked Rachel , Sutton Ryan , Raikin Steven , Lynch Mary-Katherine 
Published: September 2017

Category: Bunion, Midfoot/Forefoot Introduction/Purpose: Depression and anxiety can negatively affect outcomes after orthopaedic surgery. The relationship of depression/anxiety with patient outcomes after hallux valgus surgery is not well-studied. The purpose of this study is to evaluate our cohort of patients undergoing hallux valgus surgery and determine whether depression and/or anxiety correlate with different pain and satisfaction levels. We hypothesize that patients with depression/anxiety will have greater subjective dysfunction pre- operatively and less satisfaction after surgery when compared to those patients without depression/anxiety. Methods: This retrospective study included adult patients that had undergone surgical treatment for hallux valgus over a 2-year period. Basic demographic data was collected as well as baseline visual analog scale (VAS), SF-12 mental component, and VR-12 mental component. History of depression and/or anxiety and medications were recorded. All patients were called by phone to administer a 3-question survey at least 9 months after surgery. Data from 267 patients were available for analysis. The average patient age was 51.7 years and there were 232 females (87%). 233 patients (87%) completed preoperative functional scores, and 187 patients (70%) were reached by phone at an average of 21 months post-operatively for a satisfaction survey. Pairwise Wilcoxon tests with correction for multiple tests, unpaired student’s t tests, and a multivariate regression analysis were performed to analyze the data. Results: Of the 267 patients included in the study, 70 patients (26%) reported a history of depression and/or anxiety. Patients with a history of depression/anxiety had similar baseline demographics compared to patients without depression/anxiety including nearly 90% female sex and about 20 months post-operative follow-up (see Table 1). The group with depression/anxiety was older (55.9 years versus 50.2 years, p = 0.003), and a greater proportion of cases had severe deformity (27% versus 16%, p = 0.47). Patients with depression/anxiety scored significantly lower on baseline SF-12 and VR-12 mental scores; VAS was also lower but this was not statistically significant. Post-operative VAS and satisfaction with surgery and post-operative pain level were not statistically different between groups. Conclusion: Although patients with hallux valgus and depression/anxiety may have lower baseline mental scores and higher pain levels, their outcomes after bunion surgery are similar to those patients without depression/anxiety. The group of patients with depression/anxiety had a greater percentage of severe deformities as compared to the unaffected group yet maintained similar outcomes. Depression/anxiety may affect outcomes after certain orthopaedic procedures, however this study failed to show significantly inferior outcomes in this population of patients after hallux valgus surgery.
Return to Driving After Foot and Ankle Surgery
Authors: McDonald Elizabeth , Shakked Rachel , Pedowitz David , Winters Brian , Daniel Joseph , Raikin Steven 
Published: September 2017

Category: Ankle, Ankle Arthritis, Arthroscopy, Bunion, Sports Introduction/Purpose: The time frame for safe return to driving is an important question amongst physicians and patients following orthopaedic surgery of the right lower extremity. There is no universally validated foot and ankle psychometric test that confirms patients’ ability to safely return to driving after surgery. The purpose of the study is to report a novel, validated survey that can be used to confirm safe return to driving after orthopaedic surgery of the right foot and ankle. Methods: Patients that had undergone right achilles rupture repair, total ankle arthroplasty, and hallux valgus correction by four fellowship-trained foot and ankle surgeons were prospectively included over a trial period of 4 months. A four-question survey (see Figure 1) was administered at the 6 week post-operative office visit. Breaking reaction time (BRT) was then assessed using the Reaction Time Tester, Model RT-2 S (Advanced Therapy Products, Glen Allen, VA). A passing BRT for safe return to driving was considered 0.850 seconds. Statistical analysis was performed and Cronbach’s alpha was calculated to determine validity of the survey relative to BRT results. One hundred and twenty-two patients were included with ages ranging from 21 to 76 years (average 45 years). Results: One hundred and nine (89%) of 122 patients achieved a braking time of 0.850 seconds or less. Using time-to-event analysis, 95% of patients passed at 7.6 weeks. With a “strongly agree” or “agree” response to question 4, the survey predicts a 96% certainty of passing the BRT. At first, validating the psychometric test across all three procedures resulting in a poor Cronbach’s a of 0.6. When question 3 was removed from statistical analysis, the Cronbach’s alpha was 0.76 and the psychometric test was validated for all studied procedures. Upon calculating a composite score from the 3-question survey, the optimum threshold for a passing braking time was at least 10 points resulting in a very good AUC score of 0.948. Conclusion: This novel, three-question driving readiness survey can accurately predict a passing breaking reaction test. This provides foot and ankle surgeons with a valuable tool to objectively determine if a patient can safely return to driving after achilles repair, total ankle arthroplasty, and hallux valgus correction. Further study is required to determine whether patients who come to clinic weeks before their standard post-operative follow up appointment with the belief that they are ready to drive also pass the BRT. Additional validation of the survey would be valuable across other foot and ankle procedures.
Novel Technique for Fixation of Medial Malleolus Fractures
Authors: Meeks Brett , Kiskaddon Eric , Boin Michael , Patel Tejas , Laughlin Richard , Prayson Michael 
Published: September 2017

Category: Ankle, Trauma Introduction/Purpose: The traditional method for fixation of medial malleolar fractures has been with partially threaded (PT) lag screws extending beyond the physeal scar. Recent studies have shown fully threaded (FT) bicortical fixation in the tibial metaphysis provides superior biomechanical, radiographic and clinical outcomes. Risks with the bicortical technique include drill bit breakage, as well as injury to structures lateral to the tibial metaphysis if the far cortex is overdrilled. We hypothesized that far endosteal fixation, without penetration of the far cortex, would provide increased biomechanical strength compared to traditional PT lag screw fixation, while minimizing the risks associated with bicortical fixation. Methods: Twelve matched pairs of cadaver ankles were harvested and an oscillating saw was used to make an osteotomy at a 45- degree angle to the axilla. The medial malleolus was then re-approximated and held in the correct orientation using two kirschner wires. A 2.7 mm drill bit was used to drill a unicortical pilot hole perpendicular to the osteotomy. The left ankle was used for all PT 3.5 mm cancellous screws and all screw lengths were 45 mm. For the contralateral ankle, the 2.7 mm drill bit was used to drill to the lateral tibial cortex. The depth gauge was then used and five millimeters was added to the measured number to achieve endosteal purchase with the appropriate FT screw. Screw lengths varied in size from 55-70 mm. Screws were then placed using a torque measuring screw driver and final torque was recorded. Finally, radiographs were taken to confirm appropriate placement. Results: Average torque for unicortical PT cancellous screws was 5.02 inch-pounds with a standard deviation of 2.34. Average torque for all FT cortical screws was 7.63 inch-pounds with a standard deviation of 3.86 (Fig. 1A). A paired student’s t-test was performed comparing both fixation methods and the measured P-value was <0.01. Visual and radiographic inspection revealed no displacement of the fracture site using the FT endosteal screw (Fig. 1C). Conclusion: Our results indicate superior biomechanical torque with far endosteal fixation as compared to a traditional PT lag screw, while minimizing risks associated with bicortical fixation. This novel technique may provide added strength with minimal risk in vivo. Further clinical studies comparing radiographic results and outcomes of far endosteal fixation versus bicortical fixation are needed to ascertain the value of this fixation technique for medial malleolus fractures.
Opioid Consumption Following Foot and Ankle Surgery
Authors: Merrill Haley , Neufeld Steven , Buchanan Matthew , Cuttica Daniel , Dean Daniel , Mottla Jay 
Published: September 2017

Category: Ankle, Bunion, Hindfoot, Lesser Toes, Midfoot/Forefoot Introduction/Purpose: Orthopaedic surgeons frequently prescribe pain medications during the postoperative period. The efficacy of these medications at alleviating pain after foot/ankle surgery and the quantity of medication required (and conversely, the quantity of medication leftover) are unknown. Methods: All patients that underwent foot/ankle surgery during a three month period and met inclusion criteria were surveyed at their first postoperative visit (4-10 days after surgery). Information collected from the patients included gender, number of narcotic tablets remaining in the bottle, satisfaction with pain control, and willingness to surrender leftover narcotics to a Drug Enforcement Administration (DEA) disposal center. These data were collected prospectively. Additional data, including utilization of a perioperative nerve block, type of procedure (bony vs non-bony), and anatomic region of procedure, were collected by review of the medical record. All data were analyzed in a retrospective fashion. Results: A total of 47 surveys were filled out over the course of 4 weeks. Eighty-five percent of patients were either extremely satisfied or satisfied with their pain control. Ninety-six percent of patients had short acting opioids leftover, and 94% of patients had long acting opioids leftover. On average, there were 27 short acting and 11 long acting narcotic pills leftover at the first postoperative visit (4-10 days after surgery). Of those with leftover narcotic medications, 72% were willing to surrender them to a DEA disposal center. Conclusion: Most patients undergoing foot/ankle surgery had both short and long acting narcotic pain pills leftover at the first postoperative visit (4-10 days after surgery). While it is unknown how many patients continue to require narcotics after the first week from surgery, most patients said they would be willing to surrender any leftover opioid medications to a DEA disposal center. In the future, perhaps patients should be given information on the location of the nearest disposal center when given prescriptions for narcotics.