bluuebunny/crossref_metadata_2025_split huggingface dataset:
Anatomic Structures at Risk When Utilizing an Intramedullary Nail for Distal Fibular Fractures
Authors: Goss David , Reb Christopher , Philbin Terrence 
Published: September 2017

Category: Ankle Introduction/Purpose: Distal fibula fractures are most commonly fixated with plate and screw constructs. Conversely, modern generation fibular intramedullary nails are load-sharing devices that offer rigid internal fixation via percutaneous technique with only transaxial screws residing subcuticularly. The relative risk of damage to nearby structures is well characterized for plate and screws constructs; however, no such data is available for fibular nails. As a result, the purpose of this anatomic study was to assess the relative risk to nearby anatomic structures when implanting a current generation retrograde locked intramedullary fibular nail. Methods: This was an IRB-exempt study. Ten human cadaveric lower extremities were instrumented with a contemporary retrograde locked intramedullary fibular nail with three distal locking and two syndesmotic fixation options. The cadavers were then dissected by a single experienced orthopedic foot and ankle surgeon in a standardized fashion. The shortest distance, in millimeters (mm), between the site of procedural steps and nearby named structures of interest (i.e. sural nerve, superficial peroneal nerve and the peroneal tendons) was measured and recorded. Levels of risk were then assigned based on observed distances as high (0 to 5 mm), moderate (5.1 to 10 mm) and low (greater than 10 mm). Results: The peroneus brevis tendon was at high risk when making the distal skin incision in all specimens (Table). When reaming and inserting the nail through the distal fibula aperture, the peroneus brevis was at high risk in 7 specimens. The peroneus longus tendon was at moderate to high risk when inserting both the proximal and distal syndesmotic screws in 9 specimens. The superficial peroneal nerve was at high risk when inserting an anterior to posterior distal locking screw in 7 specimens. The sural nerve was at low risk for all procedural steps. Of note, no structures were observed to have been directly damaged. Conclusion: The current findings indicate that strict adherence to sound percutaneous technique is needed in order to minimize iatrogenic damage to neighboring structures when performing retrograde locked intramedullary fibular nail insertion. This includes making skin-only incisions, thorough blunt spreading down to bone, and maintaining close approximation between tissue protection sleeves and bone at all times. The current findings indicate that the peroneal tendons and superficial peroneal nerve are at the highest risk, and should be considered when performing relevant clinical outcomes studies.
Location of Activation of Tarsal Joints on SPECT CT Scan Predicts Preoperative Functional and Pain Scores on Supramalleolar Osteotomy Patients
Authors: Gross Christopher , Knupp Markus , Hintermann Beat , Schweizer Christine , Hirschmann Michael , Rasch Helmut 
Published: September 2017

Category: Ankle, Ankle Arthritis Introduction/Purpose: Combined single-photon emission computed tomography and conventional computed tomography (SPECT/CT) is a hybrid imaging modality that shows a combination of metabolic and structural information about the ankle. Recently, its use has expanded for pre-operative evaluation of supramalleolar osteotomies (SMO) for asymmetric ankle arthritis. It is unclear if the location of bone scan activation in other locations in the hindfoot is related to pre and post-operative functional and scores. We hypothesize that uptake in specific locations within the hindfoot can be associated with worse pre- and post- operative functional and pain scores. Methods: 85 pre-operative SMO patients with varus (37), valgus (41), or neutral (7) alignment of the hindfoot were assessed using SPECT/CT. The level of activation on SPECT/CT scans was measured. Activation was assessed on both the tibia and talus including the talonavicular, subtalar, calcaneocuboid joints and subfibular region. Pre- and post-operative functional and pain scores (AOFAS Hindfoot, FAOS, and VAS) were recorded for each patient at an average of 3.7 years post-operatively. We compared SPECT/CT imaging with pre-operative patient scores assuming equal group variance and used a Chi-square analysis to determine if failure can be related to having activation in other joints besides the hindfoot. Results: Those with talonavicular (6) activation had worse malalignment as measured by the AOFAS Hindfoot-A (alignment) subscore; they had worse a functional status as measured by the AOFAS-F (function) subscore. Patients with subtalar joint activation (10) had significantly worse (p<.05) pre-operative VAS pain scores. They also had worse AOFAS-F, AOFAS Hindfoot, and FAOS-S (symptom) scores. Those with calcaneocuboid activation (1) did not have any correlation to pre-operative pain or functional scores. Patients with subfibular impingement (7) had worse alignment based on the AOFAS-A scores. Patients with hindfoot joint activation did not have a higher rate of failure relative to other locations in the ankle. Activation in these areas were not associated with any post-operative functional or pain scores. Conclusion: Pre-operative SPECT/CT evaluation of the hindfoot before a SMO can be used to clinically correlate patient-specific factors such as pain and function in the pre-operative period. Results from this study provide prognostic information the locations of lesions that may cause patients more functional disability and pain pre-operatively and in the future.
MRI Utilization by Orthopaedic and Non-orthopaedic providers for acute or chronic ankle pain
Authors: Gross Christopher , Palanca Ariel , Chapin Russell 
Published: September 2017

Category: Ankle Introduction/Purpose: The use of MRI poses a significant expense in the ever-increasing cost of healthcare. The American College of Radiology (ACR) recommends obtaining ankle radiographs within 6 months prior to MRI in the assessment of patients with acute or chronic ankle pain. In this retrospective utilization study, we examine the compliance rate of both orthopedic and non-orthopedic providers at two academic centers. We hypothesize that there is an over utilization of resources by non- orthopaedic surgeons. Methods: We retrospectively reviewed 721 patient charts (4/2015-11/2016) who had an ankle MRI. We analyzed the preceding conservative management and subsequent non-operative or surgical care of the patient, and made note of the ordering physician and whether or not radiographs were obtained prior to ordering an MRI. We also performed an analysis of diagnosis and identified common diagnoses that were associated higher levels of non-compliance to the ACR criteria. Results: Overall, we determined that 222 of the 259 (85.7%) of the orthopedic providers obtained radiographs prior to MRI while only 271of 462 (58.7%) non-orthopedic providers followed these criteria (p<0.0001). In total, we found that 493 out of 721 (68.4%) providers ordered ankle radiographs prior to MRI. Among orthopedic providers showing non-compliance with the ACR criteria, the most common patient diagnoses were tendinopathy and not obtaining new radiographs when radiographs were older than 6 months. Among non-orthopedic providers, the most common diagnoses were edema and tendinopathy. Conclusion: We found that orthopedic providers adhered much more closely to the ACR criteria, and that there is a significant over-utilization of resources by all providers, with an overall inappropriate use percentage of 32.1%. Increasing the compliance rate could prove to be an effective mechanism for decreasing the cost healthcare in the treatment of ankle pain.
The Talar Body Prosthesis Treated End Stage Ankle Arthrosis
Authors: Harnroongroj Thos 
Published: September 2017

Category: Ankle Arthritis Introduction/Purpose: Ankle arthrosis creates patient disability. Ankle arthrodesis is treatment of choice which creates ankle stiffness and arthrosis of neighboring joints. Total ankle replacement can preserve ankle motions but the results at mid and long- term follow up needed further evaluation. Talar body prosthesis (TBP) can provide long-term satisfactory foot-ankle function of the ankle sustaining talar body damages. Due to ankle biomechanics is different to hip and knee joints. So, we inserted TBP for treating end stage ankle arthrosis. The present study evaluated outcomes at 5-10 years of follow up and described surgical technique. Methods: Between 2001 and 2011, the TBPs were inserted in 23 ankle arthrosis patients. The data were reviewed. We included grade 3 Bargon and Henkemeyer radiographic grading of ankle arthrosis and deformed talar body. The patient with neurological, hip, knee, mid-foot problems which impeded walking ability and age more than 70 were excluded. The patient consisted of 13 females and 10 males. Mean age at index operation and the latest follow up were 54.70 (39-70) and 61.17 (47-75) years old. Mean BMI at the latest follow up was 25.56 kg/m2 (21.89-29.76). Surgical technique included TBP insertion with addressing and applying tensor fascia lata at the articular end of distal tibia. Pre- and the latest follow up AOFAS (American Orthopaedic Foot and Ankle Society) ankle-hindfoot score and radiographs were reviewed. Neighboring joint arthrosis was evaluated by Kellgren-Lawrence radiographic system. The data was statistically analyzed. Results: Mean follow up duration was 6.48 years (5-10 years). All 23 TBPs maintained congruent talocrural joint. There was no prosthesis failure in term of subsidence into calcaneus and prosthetic stem perforation into talar head at the last follow up. No neighboring joint arthrosis occurred according to the radiographs. The mean range of motion of last follow up was 22.17° of plantar flexion (median 22°, ranged from 15° to 29°) and 0° to 5° of dorsiflexion. The patients could perform activity daily life. Mean AOFAS ankle-hindfoot score at preoperative period and last follow up were 40 points (Median 36, Ranged from 31 to 58) and 74 points (median 75, ranged from 61 to 83), respectively. The statistical analysis showed significant improvement of the score (p<0.001). Conclusion: TBP can provide satisfactory result of ankle-hindfoot functions at 5-10 years follow up. Advantages of the prosthesis over ankle arthrodesis and total ankle replacement included preservation of the ankle motion without neighboring joint arthrosis and no prosthesis failure.
Locked Dorsal Compression Plate Arthrodesis for Degenerative Arthritis of the Midfoot
Authors: Hirose Christopher , Coughlin Michael , Flint Wesley 
Published: September 2017

Category: Midfoot/Forefoot Introduction/Purpose: Midfoot arthrodesis remains a technical challenge. Little is known of the required magnitude of compression in order to obtain fusion. Multiple techniques have been reported, reflecting the difficulty of achieving a good result. These methods include an in situ bone graft dowel technique, dorsal staple, Kirschner wire, trans articular lag screw, and screw and plate fixation. More recently, dorsal hybrid plating, and slot graft inlay arthrodesis have been described. The purpose of this study is to describe the results of a dorsal fixed-angle locking compression plate in the setting of multiple-joint midfoot arthrodeses. Methods: A retrospective study was performed to identify 62 consecutive patients who underwent midfoot arthrodeses from June 2009 to May 2016. A total of 184 joints were spanned by dorsal fixed angle locking compression plates. The medical risk factors, etiology of arthritis, body mass index, time to union, visual analog pain scores (recorded preoperatively and postoperatively), and post-operative complications were evaluated. Patients were followed for one year. Radiographs were read by two fellowship-trained surgeons to determine the time to fusion. If union was indeterminate, a computed tomography scan was obtained, with the presence of 50% or greater bridging bone as the definition of fusion. Results: Of the joints spanned, 156 fused (83%). The average time to fusion was 19.6 weeks (Standard Deviation 21 weeks). Complications included persistent numbness (10), wound infection (2), and deep venous thrombus (1). The average VAS score diminished from 5.9 preoperatively, to 1.7 at week 6, 1.9 at week 12, 2.6 at month 6, and 3.1 at one year. Conclusion: Despite the difficulty of midfoot arthrodesis procedures in obtaining solid fusion, the dorsal fixed angle locking compression plate demonstrates a union rate, time to fusion, and complication rate that is comparable with the existing literature. The results of this study also indicate room for improvement in the design of advanced plating systems, which could incorporate more uniform joint compression combined with biologic augmentation in the hope of achieving improved radiographic and clinical results.
Optimization of the Staged scheme for the Treatment of complicated (OTA C3) Tibial Pilon Fractures
Authors: Hui Zhang 
Published: September 2017

Category: Ankle, Ankle Arthritis, Arthroscopy, Bunion, Hindfoot, Lesser Toes, Midfoot/Forefoot, Trauma Introduction/Purpose: To explore and evaluate the optimization operative strategy reported on our results using a direct approach with posterior malleolar plating in combination with staged anterior? xation in complex pilon fractures. Methods: 43 patients were diviede into group A (23 cases, posterior plating and external? xator for stage I, ORIF through anterior approach for stage II)and group B(20 cases, closed reduction and external? xator for stage I, ORIF through anterior- posterior approach for stage II) between 2013 and 2014. With an average follow-up of 16.6 months, Results: The statistics showed that there were statistically significant differences (P<0.05)between two groups in the time before definitive surgery and the operative time of the stage II surgery, but in the time before initial surgery and the operative time of the initial surgery(P>0.05). The AOFAS and MLFAS scores in the group A were better than (P < 0.05) the Group B. 4 patients in the group A had some evidence of symptomatic arthrosis compared with 6 in the group B. The rate of tourniquet paralysis for the group A was 4.35% versus 35% (P < 0.05) for the Group B. Conclusion: The optimization operative strategy offers direct visualization for reduction, and allows the anterior components to be secured to a stable posterior fragment at a later date. The staged strategy not only obtains the leg fascia chamber decompression, also shortens the waiting time for operation, reduces reduction difficulties in definitive operation.
Measuring Visualized Tendon Length in Peroneal Tendoscopy
Authors: Hull Michael , Campbell John T. , Cerrato Rebecca , Jeng Clifford , Henn R. Frank 
Published: September 2017

Category: Arthroscopy, Sports Introduction/Purpose: Tendoscopy is a relatively new method of evaluating for tendon lesions in foot and ankle surgery. Despite multiple studies describing peroneal tendoscopy use, no study exists to determine the efficacy of tendoscopy at visualizing the entire length of the peroneal tendons. The purpose of this cadaver study was to measure the length of the peroneal tendons that could be visualized using tendoscopy Methods: Ten (10) fresh cadaveric specimens, complete above- or through-knee specimens, were evaluated. Peroneal Tendoscopy was performed with routine portal placement including proximally 2 cm above the lateral malleolar tip and mid- tendon proximal to the peroneal tubercle. For the initial 5 specimens, the peroneus longus sheath was entered distal to the tendon bifurcation and proximal to the lateral cuboid under direct visualization for zone 3 tendoscopy. For the subsequent 5 specimens, a more distal point closer to the base of the 5th metatarsal was used as a landmark for skin incision and the sheath was entered at the distal aspect of the cuboid. The edges of visualized longus and brevis tendons were marked with kirschner wires placed through the tendon percutaneously under direct visualization. The tendon sheaths were then dissected and the distances from anatomic landmarks were directly measured. Results: Proximally (zone 1), both the peroneus tendons were followed circumferentially to the musculotendinous junction of the longus in all specimens. Peroneus brevis was visualized in zone 2 to an average of 19.5 mm (95% CI 16.5-22.5) from its insertion onto the base of the 5th metatarsal. Using a peroneal tubercle start point, zone 3 of peroneus longus was visualized up to an average of 17 mm (11-23) from its insertion onto the base of the 2nd metatarsal. Using a more distal start point, longus was seen up to 1.6 mm (0.3-2.9) from its insertion. The muscle belly of peroneus brevis ended an average of 1.9 mm (-3.7-7.3) above the tip of the lateral malleolus. Conclusion: The results suggest that the vast majority of the peroneal tendons can be visualized during peroneal tendoscopy. It was also noted that a more distal skin portal site may improve visualization of zone 3 of peroneus longus.
Sinus Tarsi Volume Changes with Hindfoot Position on Weight-Bearing CT Scan
Authors: Hull Michael , Rutherford Tyler , Jeng Clifford , Campbell John T. , Cerrato Rebecca 
Published: September 2017

Category: Basic Sciences/Biologics, Hindfoot Introduction/Purpose: Sinus Tarsi syndrome is a frequent cause of anterolateral foot pain following injury. Chronic lateral subtalar pain, often referred to as “Sinus Tarsi Syndrome”, is commonly reported to occur following trauma. One hypothetical epidemiological predisposing factor for sinus tarsi syndrome is flatfoot deformity with valgus hind foot alignment. Common conservative treatment includes medial heel posting to attempt to widen the sinus tarsi space and alleviate synovitic pain. Although treatment with operative intervention has been reported, no data exists to evaluate if hindfoot realignment functionally opens the sinus tarsi volume. Methods: Weight-bearing Computed Tomography (CT) scans were obtained in 5 healthy volunteers standing at rest on slanted platforms, 25 degree valgus and 25 degree varus. The volume of the sinus tarsi was measured on each scan. Cross sectional area of the sinus tarsi was measured in 3.6 mm slices from the most lateral fully enclosed image to the most lateral aspect of the middle facet of the subtalar joint. Area measurements were multiplied by cut depth (3.6 mm) and summed. Critical angle distance was measured as a straight line from the most lateral point of the lateral process of the talus to the base of the critical angle of Gissane. Subfibular distance was then measured from the most distal tip of the fibula in a straight line to the nearest point of the lateral calcaneal wall. Data were compared using a one way ANOVA and Tukey’s multiple comparison test. Results: The mean sinus tarsi volume in the valgus position was 325.1 mm3 (±88) and 313.3 (±71) for the left and right foot, respectively. In the varus position, the mean sinus tarsi volume increased to 646.8 mm3 (±169) and 599 mm3 (±203). There was a significant difference between the varus and valgus position for both feet (left p<0.01 / right p<0.05). The critical angle distance increased from 28.1 mm (±7.5) to 91.3 mm (±26) for the left foot and 26.3 mm (±7.6) to 87 mm (±27.9) for the right foot when realigned to the varus position (p<0.0001). There was not a significant increase in the sub fibular distance when repositioned from valgus to varus (p=0.06 / p=0.35). Conclusion: This study confirms that moving from a valgus to a varus position significantly increases the volume of the sinus tarsi as well as significantly increases the distance from the lateral process of the talus to the calcaneal angle of Gissane. Interestingly, subfibular distance did not significantly increase, although this may reach significance with increased samples. With confirmation that adjusting hindfoot positioning impacts lateral osseous impingement, future studies are warranted to correlate these findings with clinical symptoms.
Achilles Tendon Repair- A Systematic Review of Overlapping Meta-Analyses
Authors: Hurley Eoghan , Yasui Youichi , Gianakos Arianna , Seow Dexter , Kromka Joseph , Shimozono Yoshiharu , Megill Robin , Kennedy John 
Published: September 2017

Category: Sports Introduction/Purpose: Acute Achilles tendon ruptures (ATR) are a common sports-related injury with an incidence of between 8-37 per 100,000 per year. While there are several meta-analyses published on the optimal treatment of ATR based on randomized control trials, the reported outcomes conflict between each meta-analysis due to different methodologies. The aim of this study is to systematically review the clinical results represented in meta-analyses in the current literature on acute ATR. Methods: Two independent reviewers performed the literature search based on the PRISMA guidelines to identify meta-analyses on Achilles tendon repair. Clinical results, including the re-rupture rates, wound infection rates and overall complication rates were analyzed. Level of evidence (LOE) and methodological quality of evidence (MQOE), using the AMSTAR score, were evaluated. A statistically significant difference (SSD) was defined as p < 0.05. Each meta-analysis was categorized into one of the following subgroupings: 1) Operative vs Non-Operative Treatment (with Conservative Rehabilitation) [OC vs NOC], 2) Operative vs Non-Operative Treatment (with Functional Rehabilitation) [OF vs NOF], 3) Conservative Rehabilitation vs Functional Rehabilitation (with Operative Treatment) [OC vs OF], and 4) Open vs. Percutaneous Repair (with Conservative Rehabilitation) [OC vs POC]. Results: Four studies compared OC and NOC. Re-rupture rates ranged from 3.1-6.4% in OC and 10.0-13.0% in NOC. Two of these studies showed statistical significance in favour of OC. There was no SSD was seen in other complications. Three studies compared OF and NOF. Re-rupture rates ranged from 3.8-5.0% in OF and 6.0-11.9% in NOF, no study showed a SSD. There was no SSD in other complications. Three studies compared OF and OC. Re-rupture rates ranged from 2.13-3% in OF and 1.1-2.1% in OC, no study showed a SSD. Four studies compared OC and PSC. Re-rupture rates ranged from 2.2-4.4% in OC and 1.1-2.1% in PSC, no study showed a SSD. In all included studies there was SSD in wound infection rates, in favour of PSC. Conclusion: Overall there exists a large volume of high quality meta-analyses on Achilles tendon repair. The re-rupture rates were lower in operative treatment in all studies, even when early functional rehabilitation was used. However, while early functional rehabilitation may allow early mobility but the rehabilitation method can be demanding. Although there was no difference between percutaneous and open repair on the re-rupture rate, there was an overall reduction in wound infection after percutaneous repair. The results within this study can help determine the optimal treatment for patients.