bluuebunny/crossref_metadata_2025_split huggingface dataset:
Syndesmosis Evaluation Under WBCT: 3rd Base to Get a Cut-Off Point to Diagnosis
Authors: Protasowicki Nicolas , Carcuro Giovanni , Chaparro Felipe , Ahumada Ximena , Pellegrini Manuel J. , Ortiz Cristian A. 
Published: December 2023

Category: Sports; Arthroscopy Introduction/Purpose: Evaluation of syndesmal injury remains challenging for Foot & Ankle Surgeons. As objective data to provide an accurate preoperative diagnosis of syndesmal instability is lacking, arthroscopy has remained the Gold Standard. However, the costs and risks associated with surgery make arthroscopy challenging to indicate in all cases. Therefore, significant interest exists in determining objective criteria to safely indicate surgery. Comparative WBCT is a valuable tool, allowing a precise evaluation of the healthy and injured joints. Specifically, the difference in the syndesmal area correlates with diastasis at the inferior tibiofibular joint, while the cut value for diagnostic instability remains undetermined. Objective: To compare the difference in syndesmal area between healthy patients and patients with syndesmal sprains under WBCT. Methods: IRB approval was obtained for a retrospective case-control study. Patients with suspected syndesmal injuries from April 2019 to August 2022 were included in the case group. Patients with chronic ankle instability, age over 55 years, or surgery of the inferior limb were excluded. The control group was obtained from a previous study of comparative WBCT of the ankle joint, obtained for reasons different than trauma or instability. All patients were evaluated under WBCT by a fellowship-trained MSK radiologist. After evaluating the syndesmal area at 1 cm from the ankle joint line in an axial WBCT slice, the percentage difference from the injured to the healthy side was recorded. Demographic data were obtained from the patient chart. For those patients undergoing surgical stabilization, the operative note was examined. Statistical evaluation was performed by an independent statistician using SPSSv27 using the ANOVA test. Results: Thirty-nine patients were recruited for the study group, and a control group of 25 patients with healthy ankles was obtained. Demographics data for both groups were comparable Arthroscopy was indicated in 7/39 patients (17,9%), which confirmed diagnosis and warranted stabilization of the joint. The mean percentage area difference of the confirmed injured syndesmosis was 15,14% (IC 4,89-25,39), suspected injured syndesmosis was 9,25% (IC 3,11-15,39), and the healthy syndesmosis was 1,54 (IC 1,08-2,01). Statistically significant differences were obtained for healthy, operated, and non-operated patients with a p=0,021. Conclusion: A comparative WBCT scan and the percentage difference in the syndesmal area between the healthy, confirmed, and suspected syndesmal injury demonstrated a handy diagnostic tool. Although the limitations of this study, our results suggest that a 15% difference in the syndesmal area between healthy and injured sides might be used as the cut-off point to indicate diagnostic arthroscopy.
Tibialis Posterior Tendon Entrapment in Posterior Malleolar and Pilon Injuries of the Ankle: A Retrospective Analysis
Authors: Mason Lyndon W. , Aamir Junaid , Syziu Anxhela , Andritsos Loukas , Caldwell Robyn 
Published: December 2023

Category: Ankle; Trauma Introduction/Purpose: The Tibialis Posterior tendon (TPT) is the only tendon to come into contact with the distal tibia and is therefore at greatest risk of injury in fractures of the distal tibia. Although TPT injury has been reported rarely with injuries around the ankle they often have been missed and present late. Aim Our aim was to analyse the rate to TPT entrapment in fractures involving the posterior tibia i.e. Pilon (PLM) and posterior malleolar fractures (PMF). Methods: A retrospective analysis of PMF and Pilon fractures over an 8-year period was undertaken. Patients who had undergone surgical fixation of their PMF or PLM were identified from 2014 to 2022, using our prospectively collected database. Any fracture which had undergone a preoperative CT was included. Analysis of their pre-operative CT imaging was utilised to identify TPT entrapment, where if < 50% of the tendon cross section was present in the fracture site this was denoted as a minor entrapment and if ≥50% of the tendon was present in the fracture site was denoted as major. Results: A total of 363 patients were identified for further analysis, 220 who had a PMF and posterior 143 with Pilon injury. The incidence of TPT entrapment was 22% (n = 79) with 64 minor and 15 major entrapments. If the fracture entered the TPT sheath, there was a 45% (72/172) of entrapment as compared to 3.7% (7/190) in fractures not entering the sheath p <.001). There was no significant difference in TPT entrapment in PMF as compared to PML (p=0.353). Conclusion: In our assessment, there was a significant risk of TPT entrapment when the CT images display the fracture line entering the tendon sheath. We recommend that surgeons consider care pre-operative imaging and seek to identify the TPT intraoperatively where entrapment does occur.
UK Foot and Ankle Thrombo-Embolism Audit (UK-FATE): A Multicentre Prospective Study of Venous Thromboembolism in Foot and Ankle Surgery
Authors: Mangwani Jitendra , Mason Lyndon W. , Malhotra Karan , Houchen-Wolloff Linzy 
Published: December 2023

Category: Other Introduction/Purpose: There is wide variation in the threshold and provision of thromboprophylaxis in the treatment of foot and ankle conditions. One of the difficulties in affecting change in practice in this area is the low incidence of postoperative, symptomatic VTE. Therefore, a large number of patients need to be included in any series for meaningful conclusions to be drawn. Primary objective To observe the UK-wide variation in post-operative thromboprophylaxis, and to analyse the 90-day incidence of symptomatic venous thrombo-embolism related to: -Elective foot and ankle surgery -Trauma foot and ankle surgery -Treatment of Achilles tendon ruptures (operative and non-operative) Methods: This was a multi-centre prospective audit spanning a collection duration of 9 months. Primary outcomes included symptomatic VTE up to 90 days following foot & ankle surgery and Achilles tendon rupture and VTE related mortality up to 90 days following treatment. Secondary outcomes included methods of thromboprophylaxis used, and possible confounding variables and influencing factors for VTE. Results: A total of 10,983 patients were included from 56 sites in the UK. This was split into 51.72% trauma (n=5571), 3.78% diabetic surgery (n=415) and 45.18% elective surgery (n=4962). There was 95 VTE events across the whole cohort (0.86%). Diabetic foot disease surgery had the highest rate of VTE (Below knee amputation 5.3% and acute foot debridement 2.6%). The trauma diagnosis with the highest rate of VTE was Achilles tendon rupture (3.7%). All elective foot procedures had a VTE rate < 1% except elective tendon procedure (1.1%). Factors with statistically significant association with VTE included trauma surgery where prophylaxis stopped greater than 1day pre surgery (p=.027), non-compliance with prophylaxis (p=.001), post-surgical infection (p=.005), and the comorbidities asthma (p=.014), cancer (p=.014), dementia (p=.001), diabetes (p=.005), stroke (p < 0.001) and recent long-distance travel (p=.048). Conclusion: This is a large-scale multicentre study which recorded multiple possible confounding variables. There were 12 different chemical prophylaxis used across the study, with the highest rate of VTE in patients administered Apixaban (4.9%). The most common chemical prophylaxis used in the study was Enoxaparin (27.19%) followed by Dalteparin (20.38%). There was no evidence of a decrease in VTE if mechanical prophylaxis was used. The study identified specific diagnosis with increased risk of VTE and comorbidities.
Changes in Coronal and Sagittal Alignment of the Ankle Joint After High Tibial Osteotomy: Evaluation Using Low Extremity Scanogram and EOS Imaging System
Authors: Song Jaehwang 
Published: December 2023

Category: Ankle; Hindfoot Introduction/Purpose: High tibial osteotomy (HTO) is a useful treatment option for symptomatic knee patients with varus knee alignment and medial compartment arthritis. Changes in coronal and sagittal alignment of the knee joint have been reported in several previous studies. However, no study have investigated the changes of both coronal and sagittal alignment of the ankle joint after HTO. The purpose of this study was to investigate changes in coronal and sagittal alignment of the ankle joint after HTO. Our hypothesis was that alignment of ankle joint, as well as knee joint, change significantly after HTO. Methods: Total 46 patients (49 cases) were retrospectively analyzed after HTO for varus knee osteoarthritis. Preoperative and follow-up of low extremity scanogram and EOS imaging system were taken. The hip–knee–ankle (HKA) angle, medial proximal tibial angle (MPTA), knee tibia plafond angle (KTPA), were measured by scanogram to evaluate coronal alignment of the knee. Tibial anterior surface angle (TAS), Tibial plafond inclination (TPI), talar tilt (TT), and ankle joint axis point on the weight-bearing- line (AAWBL) were measured by scanogram to investigate coronal alignment of the ankle. Tibial lateral surface angle (TLS) and lateral knee tibial plafond angle (LKTPA) were measured by EOS to evaluate sagittal alignment of the ankle. Radiologic outcomes of the knee and ankle were evaluated pre- and postoperatively. Results: Varus alignment of the knee was corrected by significant coronal change of the HKA angle, MPTA, KTPA after HTO (P < 0.05). There was significant coronal change in TPI and AAWBL in ankle alignment (P < 0.05). The ankle joint axis point on the weightbearing axis moved laterally which was demonstrated by AAWBL. However, there was no significant difference between preoperative and follow up TAS and TT (P > 0.05). In sagittal alignment of ankle by EOS, LKTPA significantly increased after HTO (P > 0.05), but TLS showed no significant difference postoperatively (P > 0.05). Conclusion: Coronal and sagittal alignment of ankle joint was significantly changed after HTO by lateral shift of ankle joint axis and LKTPA increase after HTO. Further study is necessary to investigate the effects of the present radiologic results on clinical symptoms of the patients.
Comparison of Radiographic and Clinical Outcomes between Distal and Proximal Minimally Invasive Chevron and Akin Osteotomy for Severe Hallux Valgus Deformity
Authors: Choi Seung-Myung , Cho Byung-Ki 
Published: December 2023

Category: Midfoot/Forefoot; Midfoot/Forefoot Introduction/Purpose: The surgical treatment of severe hallux valgus (HV) deformity is challenging due to the difficulty in achieving sufficient reduction and the increased risk of complications such as recurrence, delayed or non-union. Minimally invasive surgery (MIS) has been increasingly used to treat HV deformity, with the third-generation minimally invasive Chevron and Akin osteotomies (MICA) technique being widely accepted. This retrospective cohort study aimed to compare the radiographic and clinical outcomes between the distal and proximal MICA techniques for severe hallux valgus deformity. It was hypothesized that the proximal MICA technique would provide better radiographic results due to the stronger deformity correction achieved by the proximal metatarsal osteotomy. Methods: Seventy-four feet with severe HV (defined as HVA [≥40 degrees] and/or IMA [≥20 degrees]) treated with distal MICA (40 feet) or proximal MICA (34 feet) were included in this study after at least one year of follow-up. Clinical assessment included the American Orthopaedic Foot & Ankle Society (AOFAS) score, pain visual analog scale (VAS), patient satisfaction rating, and complications. Radiographic assessments included HV angle (HVA), intermetatarsal angle (IMA), and distal metatarsal articular angle (DMAA). Results: There were no differences in the mean AOFAS score, pain VAS score, and patient satisfaction rate at the final follow-up between the two groups (all p > .05). The mean postoperative HVA, IMA, and DMAA significantly improved at the final follow-up in both groups (all p < .001). There was no significant difference in the improvement of radiographic values after surgery between the two groups (all p > 0.05). Although not statistically significant, there was a trend toward a higher recurrence and delayed or nonunion rate in the distal MICA group (7.5% vs. 2.9%, P =.218 and 10% vs. 2.9%, P =.072). Conclusion: Both types of minimally invasive techniques resulted in satisfactory outcomes in terms of significant improvement in clinical values, large deformity correction, and reasonable complication rates. However, the proximal MICA technique appears to provide more stable maintenance of deformity correction than the distal technique.
Lateralizing Calcaneal Osteotomy Performed with a Percutaneous Burr Results in a Significantly Lower Increase in Tarsal Tunnel Pressure
Authors: Siddiqui Ali A. , Troyer Wesley , Bango Jugert , Shi Glenn , Buckner Jeannie , DiTommaso Rita , Haupt Edward T. 
Published: December 2023

Category: Hindfoot; Basic Sciences/Biologics Introduction/Purpose: Single-plane calcaneal osteotomies are used to manage hindfoot deformity. Neurological complications, such as tarsal tunnel syndrome, are well-documented following lateralizing calcaneal osteotomy. Traditionally, calcaneal osteotomy is performed using an oscillating saw. No studies have investigated the effect of alternative surgical techniques on postoperative tarsal tunnel pressure. The purpose of this study was to investigate the difference in tarsal tunnel pressures following lateralizing calcaneal osteotomy performed using a high-torque, low-speed “minimally invasive surgery” (MIS) Shannon burr versus an oscillating saw. Methods: Lateral-to-medial lateralizing calcaneal osteotomy via a lateral approach was performed on 10 below-knee cadaveric specimens. This was conducted on 5 specimens using an oscillating saw (Saw group) and 5 specimens using the MIS burr (Burr group). The calcaneal tuberosity was translated 1 centimeter laterally in all specimens and transfixed using 2 Kirschner wires. Tarsal tunnel pressure measurements were collected before and after osteotomy under ultrasound guidance using a percutaneous needle barometer. Mean pre- and post-osteotomy tarsal tunnel pressures were compared between groups. Differences were analyzed using Student’s t-test. Results: The mean pre-procedure tarsal tunnel pressure in the Saw group was 25.8 ± 5.1 mm Hg and 26.4 ± 4.3 mm Hg in the Burr group (p = 0.85). The mean post-procedure tarsal tunnel pressure was 63.4 ± 5.1 mm Hg in the Saw group and 47.8 ± 4.3 mm Hg in the Burr group (p = 0.01). The change in tarsal tunnel pressure after lateralizing calcaneal osteotomy was significantly lower in the Burr group (21.4 ± 4.5) compared to the Saw group (37.6 ± 12.5) (p = 0.03). The increase in tarsal tunnel pressure was 43% lower in the Burr group compared to the Saw group. Conclusion: In this cadaveric study, the increase in tarsal tunnel pressure following lateralizing calcaneal osteotomy was significantly lower when using a burr versus an oscillating saw. This is likely due to the increased width (“kerf”) of the 3mm MIS burr relative to the submillimeter saw blade width causing increased shortening of the calcaneus. This smaller magnitude of tarsal tunnel pressure increase suggests that use of the MIS burr for lateralizing calcaneal osteotomy may decrease the risk of postoperative tarsal tunnel syndrome. Future research in vivo should be aimed at investigating this.
Patient Reported Outcomes Before and After Revision Total Ankle Arthroplasty Done In the First Two Years of a Single Surgeons Practice
Authors: McKeeman Jonathan , Higgins Margaret , Weiss Samantha N. , Lachman James R. 
Published: December 2023

Category: Ankle Arthritis; Ankle Introduction/Purpose: As Total Ankle Arthroplasty (TAA) volume continues to grow nationally, so is the need for revision TAA surgery. A foot and ankle surgeon fresh out of fellowship is likely to encounter these challenging cases soon after beginning practice. The learning curve for ankle replacement has been demonstrated in multiple studies but no such study exists for revision TAA due to the relative infrequency of this procedure. The experience of one high volume revision TAA surgeon in the first two years after fellowship is reviewed in this study. Radiographic, clinical, and patient reported outcomes are analyzed in this study. Methods: In this IRB approved study, we retrospectively reviewed prospectively collected data on 18 patients who underwent Revision Total Ankle Arthroplasty Surgery from January 1, 2018, to January 1, 2021. Patient-reported outcome (PRO) measures including PROMIS depression, physical function and pain interference CATs taken preoperatively and then at specific post- operative intervals were collected on all patients. Radiographic and clinical results were also reviewed. Patients being revised, whether single stage or two-stage, for infection were excluded. Patients converted from ankle arthrodesis to ankle replacement were omitted. Student t tests, chi-square test, and nonparametric alternatives (p <.05) we used. Results: Eighteen patients ( Average age 65.5, 50% male) underwent revision TAA average follow up 25 months. Aseptic loosening (50%) was the most common cause for revision followed by component malpositioning (28.8%). The Scandanavian Total Ankle Replacement was the most commonly revised implant in this study 83.3%. Radiographic parameters (Tibiotalar angle Tibial component positioning) improved after revision TAA. Average Promis physical function improved from 41.18 pre-op to 47.77 (p.078), depression improved from 57.64 pre-op to 49.67(p .025*), and pain interference improved from 61.3 preop to 50.55 (p .045*) after revision TAA. No differences were seen in any outcome measure with regards to time from fellowship, when assessing for a learning curve. See attached table for complete list of results. Conclusion: Revision TAA is a technically challenging procedure. One which will continue to be more and more common as ankle replacement continues to replace arthrodesis as the preferred treatment for ankle arthritis. This study did not identify a learning curve for revision total ankle arthroplasty. Outcomes were similar independent of time after fellowship the cases occurred. Patient reported outcomes, clinical outcomes, and radiographic outcomes all improved in this cohort after revision TAA.
The Variation Between Unilateral and Bilateral Weight Bearing in Hindfoot Alignment Evaluation: Part II: A Prospective In Vivo Kinematic and Plantar Pressure Study
Authors: Ji Xinyu , Wang Juntao , Zhang Yuyan , Zhu Mingjie , Zhu Lei , Xu Qingjia , Myerson Mark , Ji Bing , Li Shuyuan 
Published: December 2023

Category: Hindfoot; Midfoot/Forefoot Introduction/Purpose: When AP, lateral, and hindfoot views weight bearing XR's were taken, patients were frequently asked to stand on the foot being examined with the other foot lifted off the floor. However, we have found that alignments of the hind and midfoot during unilateral standing are different from those when bearing weight on both feet. This study compared the kinematics and plantar pressures between unilateral and bilateral standing positions in a group of asymptomatic volunteers. Methods: Ten participants (20 feet) without symptoms, previous trauma and surgical history in both lower limbs were included. Each participant first stood comfortably on both feet, then lifted the non-examined foot off the floor. Each person switched between the above two positions three times. Kinematic data was collected using an eight-camera Optitrack 3D motion capture system to reflect changes in alignments of the ankle, subtalar, and midtarsal joints. Plantar pressure distribution was assessed using a pressure platform. Paired t-tests were used to compare the metrics between the two standing positions, with statistical significance level set at P < 0.05. Results: From bilateral to unilateral weightbearing, 14 out of 21 kinematic angular parameters showed medium to high level of statistical significance (p=0.001-0.046) reflecting differences in the relative positions of the ankle, subtalar, and midtarsal joints in the two weightbearing positions resulting from pronation of the hindfoot and midfoot; the average plantar pressure change underneath the hallux (0.1616N), toes 2-5 (0.0907N), metatarsals 2-4 (0.2481N, 0.3204N, 0.2649N), midfoot (0.1794N), medial and lateral heel (0.259N, 0.246N) all showed statistically significant increase. There was a significantly higher plantar pressure increase on the medial than the lateral side of the feet. This corresponded to both the kinematic changes, and our findings in another study investigating the alignment change between the positions radiographically. Conclusion: The hindfoot and midfoot are more pronated in unilateral weightbearing than in bilateral weightbearing which may mask the severity of the deformity in a flexible cavovarus foot but increase that in a flexible flatfoot. Modification of the traditionally used unilateral weightbearing position in obtaining clinical radiographs should be considered. Bilateral WBCT scans may be a better alternative, taking advantage of allowing both feet to bearing weight naturally without concerning about one foot blocking the other during the radiographic imaging.
Chronic Achilles Tendon Rupture Reconstruction with Semitendinous Autograft Tendon: A Case Series
Authors: de Britto Costa Lucas Plens , Mann Tania Szejnfeld , Lima Ricardo Luiz Gave , Mansur Nacime Salomao Barbachan , Raduan Fernando , Nery Caio , Maffulli Nicola 
Published: December 2023

Category: Sports; Ankle Introduction/Purpose: Chronic Achilles tendon ruptures is challenging because the tendon ends are usually retracted, and if the gap between the proximal and distal stumps are of more than 6 cms with the ankle in plantarflexion the currently literature shows that semitendinous tendon (ST) autograft reconstruction has satisfactory funcional outcome. The objetive of this study is evaluate the functional outcomes after Achilles tendon reconstruction with ST. Methods: Prospective case series, level IV of evidence, authorized by Ethics Committee of our institution, assessed the clinical outcome of patients submitted to achilles tendon reconstruction between march 2021 and june 2022. The patients were diagnosed by 2 orthopaedic foot and ankle surgeons board certificated and were subjected to the following inclusion criteria: age between 18-60 years, agreeing to participate, with chronic achilles tendon rupture (> 12 weeks) and gap between proximal and distal stump larger than 6cm confirmed by ultrasound with the ankle in plantarflexion position. Demographic data was obtained, including gender, BMI and height and the full ST length was measured intraoperatively. AOFAS Hindfoot Score and Achilles Tendon Total Rupture Score (ATRS) were evaluated pre and postoperatively (last evaluation). Results: 20 patients were included, with medium age of 45 years old (range 23 to 64 )and medium gap of 6,3 cm (range 6 to 6,6). (Table 1). The pre and postoperative AOFAS-hindfoot was 71 (range 48 to 83) and 89 (range 81 to 97), respectively, and the pre and posoperative ATRS was 33 (range 30 to 47) and 88 (range 86 to 92), respectively, both with statistic significance. The medium lenght of the ST from the posterior approach was 26.3 cm and the medium VAS for pain in the ST incision was 1. There were 2 cases of superficial infection treated with oral antibiotics for 7 days of full resolution and 1 case of superficial dehiscence treated with wound dressing. Conclusion: The surgical reconstruction of AT using ST harvested from posterior approach is a safe and reliable method for treatment of chronic AT ruptures with a gap larger than 6 cm, with a significant improvement in funcional scores and just 15% of minor complications.