bluuebunny/crossref_metadata_2025_split huggingface dataset:
Ankle Arthroscopy for Diagnosis and Treatment of Full Thickness Cartilage Lesions in the Setting of Ankle Fracture
Authors: Karnovsky Sydney , Drakos Mark , Schairer William , Da Cunha Rachael 
Published: September 2017

Category: Ankle, Arthroscopy, Sports Introduction/Purpose: Ankle fractures treated with anatomic open reduction and internal fixation (ORIF) can still be associated with poor clinical outcomes. The presence of radiographically occult intra-articular chondral injury is a known entity, however the clinical relevance in the setting of ankle fractures is not well established. The purpose of this study aims to evaluate the prevalence of chondral lesions, in particular full thickness talar dome lesions, with concurrent arthroscopy in acute ankle fracture ORIF and determine if there is a correlation with patient and fracture characteristics. In addition, we aimed to evaluate the treatment effect on clinical outcomes to establish the role of concurrent arthroscopy in ankle fracture management. Methods: A retrospective chart review was conducted from prospectively collected registry data at the investigators’ institution from 2011 to 2016. All patients that underwent an acute ankle fracture ORIF with concurrent arthroscopy were identified. Patients with concomitant injuries were excluded. Baseline patient and fracture characteristics were recorded. Fracture type by the Lauge-Hansen classification as well as by anatomic location were determined. Charts were reviewed to determine the prevalence and grade of chondral lesions. The treatment performed for each chondral lesion was determined. Clinical outcomes with a minimum of one year follow up were assessed using the Foot and Ankle Outcome Score (FAOS). Results: One hundred and sixteen consecutive patients undergoing acute ankle fracture ORIF with concurrent arthroscopy were included. A chondral lesion was identified in 78% (90/116). Of those, a Grade IV full thickness talar dome chondral lesion was identified in 43% (39/90). Patient age was a significant predictor, with patients less than thirty being less likely to have a chondral injury compared to those greater than thirty (59% vs 85%, p=0.0077). Of the patients that sustained a dislocation at the time of injury, 100% had a chondral lesion which was statistically significant (p=0.039). Patients with complete syndesmosis disruption and instability were also more likely to have a chondral lesion (96% vs 73%, p=0.013). Patients with chondral lesions had statistically significant worse clinical outcomes than those without (Table). Conclusion: Arthroscopy performed concomitantly with ankle ORIF is useful in diagnosing chondral injuries. In particular, full thickness talar dome chondral lesions are quite common. Increased fracture severity, as indicated by the presence of a dislocation at presentation, and a syndesmotic injury may be more likely to present with a chondral lesion and thus should raise suspicion and prompt evaluation. The presence of a concurrent talar chondral injury has a negative impact on clinical outcomes. Concurrent arthroscopy allows for simultaneous diagnosis and acute treatment of full thickness talar lesions.
Ultrasonographic Assessment of Synovitis with Lessor Toe Deformity Due to Rheumatoid Arthritis
Authors: Kashiwagura Takeshi , Nozaka Koji , Kura Hideji , Aonuma Hiroshi 
Published: September 2017

Category: Lesser Toes Introduction/Purpose: [Introduction] In recent years, joint ultrasonography has been widely used for the diagnosis and treatment of rheumatoid arthritis (RA), allowing visualization of synovitis. Its clinical usefulness in early diagnosis and evaluation of disease activity has been reported. Continuous inflammation, osteochondral destruction, and soft tissue destruction due to synovitis in toe joints result in various clinical pictures of the foot. In the lateral toes in the forefoot, subluxation or luxation of the metatarsophalangeal (MTP) joints may occur, leading to painful callosities and resultant disturbance in activities of daily living. Few reports have addressed toe deformity and joint ultrasonographic findings of synovitis in the forefoot. In this study, lateral MTP joints were assessed using joint ultrasonography in RA patients to examine the correlation with deformity. Methods: [Subjects] Seventy feet of 61 RA patients were examined in the outpatient clinic of our hospital. Patients who underwent surgery were excluded. The mean age of the patients was 66 years (24 to 92 years), and the mean duration of disease was 12 years and 9 months (1 month to 40 years). Biologic products were used for 23 feet. Joint ultrasonography was performed by the same examiner, using the same room and apparatus. Synovitis was defined as Grade 1 or more as determined by the power Doppler method. Based on foot radiographs in upright position obtained before and after ultrasonography, patients with luxation, subluxation, and joint fissure narrowing were classified into the deformity group, those with bone erosion and geode formation into the bone erosion group, and lack of abnormal findings into the normal group. Results: [Results] Synovitis was found in MTP joints in 41 (14.6%) of 280 toes. The incidence rates of synovitis in the deformity group, the bone erosion group, and the normal group were 27.3%, 13.1%, and 6.7%, respectively. Synovitis was found in 21.7% of patients on therapy with biologic products and in 38.3% of those without such therapy. There were no significant differences in the mean duration of the disease, visual analogue scale score, erythrocyte sedimentation rate, matrix metallopeptidase 3 level, or health assessment questionnaire score among the 3 groups. Conclusion: [Discussion] Synovitis was also found in patients who showed no changes on imaging of the toes. Synovitis persisted in some patients even after establishment of toe deformity. Drug therapy, intensification of conservative therapy, and synovectomy should be considered to prevent further deformation.
Audit changes practice; simple education intervention can lead to better outcome for ankle fractures undergoing surgery
Authors: Kheiran Amin 
Published: September 2017

Category: Ankle, Trauma Introduction/Purpose: Unstable ankle fractures are common orthopaedic injuries and majority requires open reduction and internal fixation (ORIF). The goal of surgery is to achieve anatomical reduction and stable fixation of fracture. Recent literature reports malreduction rate as high as 25% to 33%. There is emerging evidence that malreduction leads to poor patient reported outcome (PROMs) and may render additional surgery. The aim of this study was to evaluate the quality of anatomical reduction and surgical fixation of ankle fractures and the effect of a simple education intervention on the adequacy of reduction of these fractures. Methods: An audit cycle was completed starting with retrospective review (phase 1) of 114 consecutive cases of ankle fracture that underwent ORIF between October 2006 and December 2007. Data was retrieved from theatre log and PACS. Age, fracture morphology, time to surgery, time to revision surgery and the quality of anatomical reduction were assessed by three surgeons using three radiological parameters (Pettrone’s criteria + Weber’s dime test). Paediatrics, pathological fractures, open fractures were excluded. The results were conveyed and interventions in the form of regional teaching and introduction of radiological criteria were implemented. Phase 2 (re-audit) was conducted with prospective review of 72 cases between December 2015 and June 2016. Inter-rater reliability was determined using kappa value. Chi- square test was used to compare malreduction rates between 2 phases. Logistic regression was performed for age, gender, time to ORIF with regards to revision surgery. P value < 0.05 was considered significant Results: Results of initial cohort showed significant rate of malreduced fixation in 25% of cases (29 out of 114). After implementation of interventions, malreduction rate reduced to 12.6% (9 out of 72). Of these nine malreduced cases, 3 cases underwent early revision surgery within the first 6 weeks of surgery. There was no significant correlation between age, gender and time to surgery, and time to revision surgery within 3 months of surgical fixation (p = 0.4). Using three radiological parameters (Weber’s dime test, tibiofibular overlap and medial clear space) the mean kappa values for inter-rater reliability was 0.786 (0.727- 0.861), representing a substantial agreement using three radiological parameters in order to avoid failure and or further surgery. Conclusion: This study demonstrates that simple education intervention locally can lead to better understanding of fixation and reduce the rate of malreduction of these fractures. We suggest using three radiological parameters in correction of corresponding anatomy of ankle mortise is a reliable tool to avoid malreduction. Malreductions were more likely to occur in complex fractures with syndesmotic injuries.
Which Surgical Method is More Effective in the Fifth Metatarsal Base Fracture?
Authors: Kim Jun-Beom , Ahn Chi , Park Byeong-Seop 
Published: September 2017

Category: Trauma Introduction/Purpose: The aim of this study was to evaluate and compare the clinical and radiological results of internal fixation with headless cannulated screw and locking compression distal ulna hook plate for the fracture at the base of fifth metatarsal bone, Zone 1. Methods: From April 2012 to April 2015, thirty cases (29 patients) were evaluated retrospectively. The mean follow up periods was 13 months. There were divided two groups based on use of the screw (group A, n=15) or the plate (group B, n=15).We measured the displacement to diastasis of the fracture on the foot oblique radiographs taken pre- and post-operatively in each group, checked the time to bone union and the difference of the reduction distance in each group. Clinical results were evaluated using American Orthopedic Foot and Ankle Society (AOFAS) midfoot score at 12 months postoperative. Results: In group A, the mean time to union was 54.2±9.3 days, the mean displacement to diastasis improved to 0.3±0.4 mm postoperatively (p<0.001), and the mean reduction distance was 2.9±1.0 mm. In group B, the mean time to union was 41.5±7.0 days, the mean displacement to diastasis improved to 0.06±0.2 mm postoperatively (p<0.001), and the mean reduction distance was 4.1±1.6 mm. AOFAS score was verified 97.7±3.4 in group A and 98.2±3.2 in group B. The time to union was significantly different between groups A and B (p=0.01).There were no complications. Conclusion: We suggest that the plate is more effective method for the shorter union time in surgical treatment of fifth metatarsal base fractures.
Mid- to Long-Term Results of Supramalleolar Osteotomy
Authors: Krähenbühl Nicola , Zwicky Lukas , Bolliger Lilianna , Hintermann Beat , Knupp Markus 
Published: September 2017

Category: Ankle Arthritis Introduction/Purpose: Good clinical and radiographic short-term results have been reported for patients who underwent realignment surgery of the hindfoot for treatment of early- and mid-stage ankle osteoarthritis. However, no mid- to long-term results have been reported. The aim of this study was to gain a better insight on the indications and contraindications for supramalleolar osteotomies. More specific, we assessed the survival rate of a consecutive cohort of 294 patients who underwent supramalleolar osteotomy for ankle osteoarthritis and investigated the effect on functional outcome, pain relief and patients’ satisfaction. Risk factors for failure were additionally determined. We hypothesized, that realignment surgery is a valuable treatment option for young and physically active patients suffering from early to mid-stage ankle osteoarthritis. Methods: Two hundred and ninety-four patients (298 ankles) underwent realignment surgery between December 1999 and June 2013 in our institution. For four patients who were operated on both feet, only the measurements from the foot operated first were used for further analysis. The patients were assessed clinically and radiographically preoperatively, six and 16 weeks postoperatively and thereafter annually. The examination was done by independent examiners who were not involved in the treatment of the patients or analysis of the data. Kaplan-Meier survival analysis was performed with total ankle replacement and arthrodesis of the ankle joint as endpoints. A Cox proportional hazards model was performed to identify risk factors for failure. Results: The mean time to follow-up was 5.0 ± 3.7 years. The overall five-year survival rate was 88%. Thirty-eight patients (12.9%) either underwent secondary total ankle replacement or ankle arthrodesis (thirty total ankle replacements, eight ankle arthrodesis). A lost to follow-up was reported in eleven patients (3.7%). Overall, the AOFAS Hindfoot score increased from 53.2 preoperatively (SD, 19.9) to 72.7 (SD, 19.2) postoperatively. Risk factors for failure following realignment surgery were age at the time of surgery and a Takakura score of 3b preoperatively. An interaction by trend was also found between age and smoking, indicating that the increased risk in elderly patients was larger in smokers than in non-smokers at the time of surgery. Conclusion: We found good mid- to long-term results for supramalleolar osteotomies in patients with ankle osteoarthritis. The present data suggests that corrective osteotomies need to be considered in the surgical treatment of young and active patients with early- to mid-stage ankle osteoarthritis (Takakura stage 1 to 3a). This is particularly important, as ankle replacement at young age cannot be considered a lifetime solution. However, care should be taken in elderly patients who smoke at the time of surgery.
Posterior tibial tendon integrity can be screened using plain anteroposterior foot radiography
Authors: Lee Seung Yeol , Park Moon Seok , Sung Ki Hyuk , Chun Sangho , Kim Sung Jin , Sangyeop Shin , Choi Hyun , Koo Seungbum , Lee Kyoung min 
Published: September 2017

Category: Hindfoot Introduction/Purpose: Posterior tibial tendon’s condition has traditionally been evaluated using ultrasonography or magnetic resonance imaging, but recent advancements in radiography have increased the resolution of radiographic soft tissue images. We performed this study to examined whether the posterior tibial tendon could be screened using anteroposterior foot radiographs, based on interobserver agreement and accuracy. Methods: We retrospectively evaluated consecutive patients who underwent weight-bearing foot radiography and ultrasonography based on a suspicion of posterior tibial tendinopathy. The integrity of the posterior tibial tendon was evaluated by two orthopaedic surgeons (8 years and 3 years of experience) using foot radiographs, and scored as having normal or abnormal tendon integrity (Fig). We evaluated interobserver agreement between the two surgeons, and the ultrasonography and radiography findings were compared to evaluate diagnostic accuracy. Results: We included 21 patients with a mean age of 51.5 ± 15.7 years (5 men and 16 women). Ultrasonography revealed 4 patients with normal tendon integrity, 6 patients with tenosynovitis and no tendinopathy, 8 patients with tendinopathy and tendon continuity, and 3 patients with loss of tendon continuity. The surgeons provided consistent radiographic findings for 81.0% of the patients (17/21; kappa = 0.576, p = 0.007). Based on the ultrasonographic findings, the surgeons provided accuracies of 76.2% (16/21) and 61.9% (13/21). Conclusion: The results indicate that weight-bearing anteroposterior foot radiography can be used to evaluate posterior tibial tendon integrity, which may allow physicians to predict the prognosis of patients with PTTD, to determine the extent of surgical treatment, and to evaluate the postoperative tendon integrity.
Significant Differences Exist in Patient Demographics of Foot and Ankle Surgeries between High Quality Prospective Studies and National Databases
Authors: Lin Zilan , Boaz Ray , Gross Christopher 
Published: September 2017

Category: Trauma Introduction/Purpose: Several high profile studies have compared surgical and non-operative treatments in specific types of major foot and ankle surgeries and serve as management guidelines for many Orthopaedic surgeons. However, the external validity of these studies has not been examined and should be confirmed in order to confidently apply the study conclusions to the national population and modify clinical practice. The purpose of the current study was to compare patient demographic information collected from major high quality, prospective studies in foot and ankle surgeries and from same surgical procedures recorded in a nationwide database of the United States patient population. Methods: Patient demographic information from surgical procedures for achilles tendon rupture, syndesmotic injury, calcaneal fracture, and lisfranc injury were pulled from American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database between 2005 – 2014 by using CPT codes listed in Table I. The same information was collected from several randomized control or prospective cohort studies identified for each type of procedure (Table I). Patient age and body mass index (BMI) were compared by using two sample T-test, while Fisher’s exact test was used to compare patient sex. Study data on age and BMI that did not provide both mean and standard deviation were not included in analysis. Results: In the NSQIP database, 1,633 achilles tendon repair and 8,852 syndesmotic injury cases were identified, but few calcaneal fracture surgeries and no lisfranc injury cases were found. For surgical cases with syndesmotic injury repair, age, sex and BMI all differed significantly between NSQIP data and the aggregate values of published studies, with the NSQIP patients being older and have more females and larger BMI (Tables II-IV). By comparing individual study data with NSQIP, 1 of 3 studies showed the same trend in age, 2 of 3 in sex, and 1 of 1 in BMI. For cases with Achilles tendon rupture repair, both aggregate and individual comparisons with 2 studies showed statistical difference on age, with NSQIP patients being older (Table II). Conclusion: Although the results were somewhat mixed, statistical significance did exist in patient demographic characteristics between published clinical data and a national database in the same foot and ankle surgeries. Caution should be warranted when interpreting clinical studies and before generalizing it onto the national population.
Pes Planus and Distal FIbular Stress Fractures
Authors: Liu Jet , Granberry William 
Published: September 2017

Category: Ankle, Hindfoot Introduction/Purpose: Fibular stress fractures accounts for 4.6% to 21% of all stress fractures. There have been isolated reports of distal third fibular stress fractures within 4-7 cm of the tip of the lateral malleolus in young and athletic patients related to overuse injuries. We examine a case series of middle aged female patients with planovalgus foot deformities and associated hindfoot valgus who presented with distal third fibular stress fractures. We propose that this type of distal fibular stress fracture is a result of increased stress loading of the distal fibula at the superior margin of tibio-fibular interosseous ligaments. Methods: From October 2015 through September 2016, we evaluated six patients (six cases) who presented to Baylor College of Medicine foot and ankle specialty clinic. These patients were found to have distal fibular stress fractures. Detailed initial history was documented. The diagnosis of distal fibular stress fracture was confirmed with both clinical examination and radiographic evidence among all patients. Additionally, all patients were found to have planovalgus deformity with associated hindfoot valgus. Radiographic measurements were taken in all patients, including lateral talo-calcaneal angle, Meary’s angle, calcaneal inclination angle, and AP tibio-talar angle. Distance of distal fibular stress fracture location to tip of lateral malleolus, as well as the distance between medial cuneiform and 5th metatarsal were measured. Single independent observer performed all measurements. Results: Among the six patients in the study, all were female, with average age of 58 years (45-64). Four patients carried the diagnosis of osteopenia and/or osteoporosis from DEXA scan. There is no evidence of association with tobacco use or alcohol use. The mean radiographic distance between location of stress fracture to tip of lateral malleolus is 5.8 cm (4.2cm-7 cm). There was evidence of pes planus from Meary’s angle, which averaged 6.7° (3°-11°) convex downward, and measurement of calcaneal inclination angle averaged 19° (13°-30°). Furthermore, measurement of tibio-talar angle averaged 1.7° valgus alignment consistent with chronic hindfoot valgus deformity. While all patients were treated successfully with immobilization, one patient underwent medial calcaneal osteotomy to correct the hindfoot valgus after recurrent fracture. Conclusion: It is hypothesized that increased stress loading of the fibula due to lateralization of the load axis contributes to this condition. The apex of this stress culminates in the lateral aspect of the fibula above the distal tibio-fibular ligament complex and results in a characteristic valgus fracture of the fibula. The increased stress from deformity results in the fracture rather than increased load from exercise or other repetitive stress. The significance of this proposition is that recognition of this type of fracture should lead the clinician to address the underlying planovalgus deformity in the treatment of this fracture type.
How Accurate is Clinical Evaluation in Hindfoot Coronal Alignment?
Authors: Lopez Valeria , Slullitel Gaston , Calvi Juan Pablo , Alvarez Victoria , Calvo Ana 
Published: September 2017

Category: Ankle Introduction/Purpose: Hindfoot coronal alignment has to be considered in the assessment of patients with foot and ankle complaints, since it guides treatment of certain pathologies. Even when there are multiples techniques described for clinical and radiographic analysis, none of them are widely accepted. The purpose of the present study was to assess the correlation between clinical and radiographic hindfoot alignment measures and to evaluate the reproducibility of both methods. Methods: We evaluated 85 patients with foot and/or ankle symptoms. Hindfoot clinical alignment was evaluated through photographs and radiographic alignment was quantified on Long Axial View radiographs. Measurements were made by two observers. Results: Intraobserver ICC for clinical analysis was good for both observers (ICC 0.78 for each one). Interobserver ICC was moderate for both measurements (ICC 0.58 and 0.56). Regarding radiographic assessment, there was significant intraobserver reliability (observer 1: r = 0.95 and observer 2: r = 0.99; P = <.0001). The interobserver reliability was also significant, r = 0.92 for the first measurement and r = 0.95 for the second measurement; P = <.0001. The correlation between both methods was weak for both observers. Observer 1: ICC 0.072; P = .24 for the first measurement and ICC 0.167 P = .029 for the second measurement. Observer 2: ICC 0.23 P = < .001 for the first measurement and ICC 0.137 P = .021 for the second measurement. Conclusion: We found a weak intra and interobserver correlation between clinical and radiographic assessment. However, we emphasize the importance of performing a complete clinical evaluation and to complement it with a standardized radiographic examination, including a reproducible technique and measurement method.