bluuebunny/crossref_metadata_2025_split huggingface dataset:
Postoperative Rehabilitation Protocols May Affect Rates of Achilles Tendon Re-Rupture after Acute Surgical Repair: A Systematic Review
Authors: Ubillus Hugo A. , Mosquea Thelma R. Jimenez , Walls Raymond J. 
Published: December 2023

Category: Ankle; Hindfoot Introduction/Purpose: Acute achilles tendon ruptures (AATR) are the most common tendon rupture in the lower limb with an incidence of up to 37 patients per 100,000 patient population annually. Several different guidelines exist on time to full weight bearing after AATR repair. Advantages of surgical management of AATR repairs are to maximize function of the tendon and reduce post-operative complications such as re-ruptures. A systematic review of the literature was performed which evaluated post-operative rehabilitation protocols, their complications and if an optimal post-operative treatment algorithm can be determined. Methods: In October 2022, MEDLINE, EMBASE and Cochrane Library databases were systematically reviewed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The level of evidence (LOE) and quality of evidence (QOE) were evaluated, and statistics on clinical outcomes, post-operative management and complications were calculated. Results: Eleven studies with 437 patients were included. Two studies were LOE I, three were LOE II, three were LOE III and three studies were LOE IV. Mean post-operative follow-up was 33.4 ± 31.2 months. Weighted mean post-operative return to full-weight bearing (FWB) was 4.8 ± 6.4 weeks. Post-operative return to neutral ankle position was achieved at an average of 4.6 ± 3.9 weeks. The overall complication rate was 3.0% (16 of 420 patients) with surgical wound infection (1.9%) and re-rupture (1.2%) the most common. Seven studies described an early rehabilitation protocol that commenced within 4 weeks from surgery. Subgroup analysis showed that early full weight-bearing (≤4 weeks) was associated with a higher re-rupture rate: 1.5% versus 0.7%. Conclusion: This systematic review demonstrated marked heterogenicity in reported rehabilitation protocols after AATR repair. While the risk of re-ruptures after surgical repair are low, we found that rehabilitation protocols that incorporate early weight- bearing within 4 weeks have a markedly increased risk of re-rupture. While there is increasing use of early rehabilitation after surgical repair of achilles tendon ruptures, further study is required to determine the optimal protocol to optimise outcome while decreasing the risk of failure.
Primary Arthrodesis vs Open Reduction Internal Fixation for Lisfranc Fracture-Dislocations: A Cost Analysis
Authors: Ochuba Arinze Jason , Murdock Christopher J. , Xu Amy L. , Snow Morgan , Schmerler Jessica , Leland Christopher R. , McDaniel Claire , Aiyer Amiethab A. 
Published: December 2023

Category: Midfoot/Forefoot; Trauma Introduction/Purpose: Lisfranc fracture-dislocation is an uncommon but serious injury that currently lacks universal consensus on optimal operative treatment. Two common fixation methods are open reduction and internal fixation (ORIF) and primary arthrodesis (PA). The objective of this study is to analyze the cost difference between ORIF and PA of Lisfranc injuries, along with the contribution of medical services to overall costs. Methods: This was a retrospective cost analysis of the MarketScan database from 2010-2020. Patients undergoing primary ORIF (CPT code 28615) versus PA (28730 and 28740) for Lisfranc fracture-dislocation were identified. The primary independent variable was ORIF versus PA of Lisfranc injury. Costs accrued due to operative management was the primary objective, and was analyzed according to net payment, total payment, coinsurance, copayment, deductible, and coordination of benefits per savings (COB/savings) amounts. Outpatient surgery setting (hospital versus ambulatory surgical center (ASC)) and requirement for secondary arthrodesis within the primary ORIF group were secondary independent variables. The utilization of and costs contributed by medical services were secondary outcomes. These included outpatient clinic visits, foot radiographs, lower extremity magnetic resonance imaging (MRI), lower extremity computed tomography (CT), physical therapy (PT), and opioid prescriptions. Student’s t-test, chi-squared test, and Poisson multivariable regression were used for statistical analysis, with significance set as P < 0.05. Results: From 2010 to 2020, 7,268 patients underwent operative management of Lisfranc injuries, with 5,689 (78.3%) ORIF and 1,579 (21.7%) PA. Of those undergoing initial ORIF, 22 (0.39%) were converted to secondary arthrodesis at a mean ± standard deviation of 10.2 ± 12.1 months after the index surgery. PA was independently associated with increased net payment, total payment, and coinsurance. When compared to primary ORIF, patients undergoing PA utilized more clinic and PT visits and imaging sessions. However, primary ORIF with secondary arthrodesis was associated with more clinic visits, imaging, and generated higher costs from these medical services compared to PA alone. Within hospital and ASCs, PA was associated with increased net and total payments. However, out-of-pocket (OOP) costs were found to be higher in ASCs. Conclusion: Treatment of Lisfranc fracture-dislocation with PA is associated with higher initial costs compared to ORIF with subsequent secondary arthrodesis. Conversely, secondary arthrodesis demonstrated significantly higher costs and resource utilization compared to primary procedures. Specific cost drivers for PA and secondary arthrodesis were clinic visits and perioperative imaging.
PROMIS Scores for Chronic Plantar Fasciitis Before and After Gastrocnemius Recession
Authors: Scheinberg Mila , Sanchez Thomas , Shah Ashish 
Published: December 2023

Category: Ankle; Hindfoot Introduction/Purpose: There has been an established relationship between increased loading on the Achilles tendon and tension on the plantar fascia. This supports the idea that either tight gastrocnemius and soleus muscles or contractures of the Achilles tendon are risk factors for plantar fasciitis. Gastrocnemius recession has gained popularity as a viable surgical intervention for cases of chronic plantar fasciitis due to isolated gastrocnemius contracture. To our knowledge, this is the first study to investigate PROMIS scores in patients with plantar fasciitis before and after gastrocnemius recession. Methods: The Electronic Medical Record was queried for medical record numbers associated with Current Procedural Terminology code 27687 (gastrocnemius recession). Our study included all patients with a preoperative diagnosis of chronic plantar fasciitis with treatment via isolated gastrocnemius recession with one-year minimum follow-up. 40 patients were included in our study. Patient variables were collected via chart review. Preoperative and postoperative PROMIS scores were collected in the clinic. Results: Preoperative and postoperative PROMIS scores improved for physical function and pain interference from 39.27 and 62.78 to 44.54 and 56.5 (p=0.0005, p=0.0001) respectively, PROIMS Depression scores were not significantly different (p=0.6727). VAS scores significantly decreased from 7.05 to 1.71 (p < 0.0001). Patients with preoperative peripheral neuropathy had significantly lower improvement in PROMIS physical function scores (p=0.0029). Tobacco use led to significantly lower improvement in in PROMIS depression (p=0.0202). Conclusion: Gastrocnemius recession is an effective option for patients with refractory pain in plantar fasciitis. Our PROMIS and VAS data confirm this procedure's utility and highlight its ability to significantly decrease pain and improve physical function in patients with chronic plantar fasciitis. We believe we have added to the literature by incorporating the, inherently superior, PROMIS scores. Based on the results of this study, the authors recommend gastrocnemius recession for patients who fail conservative management for plantar fasciitis.
Prospective Evaluation of Rate of Fusion with Augment Injectable Bone Graft
Authors: Shaheen Philip J. , Priester Jacob , Giza Eric , Kreulen Christopher D. 
Published: December 2023

Category: Hindfoot; Basic Sciences/Biologics Introduction/Purpose: Augment® Bone Graft is a mixture of rhPDGF-BB, beta-TCP and bovine collagen which has received FDA approval for use as a substitute for autografts during hindfoot and/or ankle arthrodesis. Although a recent meta analysis demonstrated that the rhPDGF-BB and beta-TCP mixture has comparable CT fusion rates and radiographic union rates to those of autografts, these studies excluded patients with prior joint site arthrodesis. In our study, we specifically use Augment® Injectable Bone Graft (AIBG) which has only very recently received labeling change approval. The goals of our study are to assess fusions rates in patients who receive AIBG during hindfoot and/or ankle arthrodesis, and then subsequently compare fusion rates between primary vs. revision hindfoot and/or ankle arthrodesis as primary outcomes. Methods: We prospectively enrolled patients aged 18-85 who underwent subtalar, calcaneocuboid, talonavicular, and/or ankle arthrodesis from one of two academic surgeons including both primary and revisions fusions. The patients received AIBG and were excluded if any other graft material was used. Demographic data and patient reported outcomes were collected preoperatively and at follow-up visits including Visual Analog Pain Scale (VAS), Foot Function Index (FFI), Foot and Ankle Ability Measure (FAAM) Sports Subscale, and Veterans Rand 12 (VR-12) physical and mental subscores. Patients were followed at 2 weeks, 6 weeks, 3 months, 6 months, 1 year, and 2 years postoperatively. The primary outcome measure was fusion rate via CT scan at 4 months with secondary outcomes consisting of the patient reported outcome data and rate of revisions. Results: 62 patients met inclusion criteria, 50 patients had a 4-month postoperative CT scan to assess for fusion with 78% of the CT scans (39 out of 50) demonstrating fusion at that time. There were only 3 revision fusion patients, with 1 of the 3 failing to fuse. 54 of the patients were followed through their 6 month visits, 44 patients through 1 year, and 24 patients were seen for their 2-year follow-up visit. All patient reported outcomes demonstrated improvement from preoperatively to final follow-up with VAS scores improving from 5.52 to 3.21, FFI improving from 57.87 to 35.64, FAAM-sports improving from 18.65 to 29.30, VR-12 Physical improving from 28.67 to 35.18, and VR-12 Mental improving from 44.27 to 47.74. Conclusion: This prospective study demonstrates that Augment® Injectable Bone Graft is an acceptable alternative to allograft for either primary or revision hindfoot arthrodesis procedures with 78% of patients achieving fusion on a 4-month postoperative CT scan and with steady noted improvement in multiple validated patient-reported outcome measures.
Prospective Randomized Controlled Trial Between Fibula Intramedullary Nail Fixation vs Open Reduction and Internal Fixation for the Surgical Management of Unstable Ankle Fractures
Authors: Lee Sung Hyun , Jo Yang Hun 
Published: December 2023

Category: Ankle; Trauma Introduction/Purpose: The fundamental concept of open reduction and internal fixation (ORIF) of unstable ankle fractures was anatomical reduction and firm fixation that allow early mobilization and rehabilitation. On the other hand, ORIF of ankle fractures is associated with complications including wound dehiscence, necrosis and infection, prominent hardware and failure. Closed reduction and intramedullary fixation (CRIF) using fibula nail was emerged as additional surgical option for unstable ankle fractures especially in elderly and medical high-risk patients. We hypothesized that fibula nailing for unstable ankle fractures would have similar functional outcomes to standard ORIF. The purpose of this study is to perform a prospective randomized study to compare clinical outcomes, bone union, and postoperative complications between ORIF and CRIF using fibula nail. Methods: A total of 59 patients (32 men, 27 women) with the mean age of 50.2 years were prospectively randomized to undergo standard ORIF or fibular nailing for unstable ankle fractures: those who underwent ORIF (31 patients 14 men, 17 women) and those who underwent CRIF using fibula nail (29 patients; 18 men and 11women). Exclusion criteria of fracture characteristics were open fracture and highly comminuted fibula fractures. Functional scoring including VAS, AOFAS and FAOS were evaluated at minimum postoperative 2 years follow up. In addition, union period, reduction status of fracture and ankle mortise at postoperative CT scan, complications including wound problem and posttraumatic arthritis were evaluated. Results: The VAS, AOFAS, and all FAOS subscales were not significantly different between two group at 2 years postoperatively (all, p>0.05). Significantly fewer infections and wound complication occurred in the fibula nail group. (p < 0.05; ORIF group (12.9%), fibula nail group (0%)). Postoperative at fracture site of fibula was high in fibula nail group (p < 0.05; ORIF group (0%), fibula nail group (13.7%)), but there were no significant differences in the status of mortise and the rate of posttraumatic arthritis (all, p>0.05). Conclusion: We concluded that the fibula nail allows acceptable reduction and secure fixation of unstable ankle fracture, with low soft tissue complication rate than ORIF. Considering the property closed reduction, the fibula nail would be an excellent treatment option for patients with unstable ankle fractures when indications is well selected
Radiographic Anatomy of the Lateral Ankle Ligament Complex: A Cadaveric Study
Authors: Tansey Patrick J. , Robbins Jordan , Stahel Shepherd A. , Morris Randal , Jupiter Daniel , Chen Jie , Panchbhavi Vinod 
Published: December 2023

Category: Ankle; Sports Introduction/Purpose: Lateral ankle sprains are common orthopedic injuries that may progress on as chronic lateral ankle instability (CLAI). Great care must be taken to restore precise anatomic relationships of the lateral ankle ligament complex (LALC) in the surgical management of CLAI. This study aimed to quantify the radiographic relationships between the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and prominent osseous landmarks visible under fluoroscopy to assist in perioperative practices for minimally invasive surgery (MIS) for CLAI. Methods: Ten fresh frozen ankle specimens were dissected to expose the LALC and prepared by threading a radiopaque filament through the ligamentous footprints of the ATFL and CFL. Lateral ankle fluoroscopic images were obtained and digitally analyzed to define dimensional characteristics of the ATFL and CFL. Directional measurements of the ligamentous footprints relative to the lateral process of the talus and the apex of the posterior facet of the calcaneus were also calculated. Results: Dimensional measurements of the ATFL included a mean length of 9.3 mm, fibular footprint of 9.4 mm, and talar footprint of 9.1 mm. Dimensional measurements of the CFL included a mean length of 19.4 mm, fibular footprint of 8.2 mm, and calcaneal footprint of 7.3 mm. From the lateral process of the talus, the fibular attachment of the ATFL was found 13.3 mm superior and 4.4 mm posterior, while the talar attachment was found 11.5 mm superior and 4.8 mm anterior. From the apex of the posterior facet of the calcaneus, the fibular attachment of the CFL was found 0.2 mm inferior and 6.8 mm anterior, while the calcaneal attachment was found 14.3 mm inferior and 5.9 mm posterior. Conclusion: The ATFL and CFL were radiographically analyzed in a unique manner and localized in reference to two prominent osseous landmarks. These findings may assist in perioperative practices for keyhole incision placement and arthroscopic guidance.
Sagittal Orientation and Variabilities of the Anatomical Insertional Footprint of the Achilles Tendon: A Cadaveric Study
Authors: Maher Moustafa A. , Zhu Mingjie , Baldini Todd , Hunt Kenneth , Myerson Mark , Li Shuyuan 
Published: December 2023

Category: Hindfoot; Sports Introduction/Purpose: New surgical techniques for Achilles tendon insertional pathology are evolving rapidly. Whether via open surgery, minimally invasive, or endoscopic approaches, more information about the Achilles' insertional footprint is needed to help surgeons with decision making. This study investigated the footprints of the Achilles insertion in sagittal orientation to delineate the anatomical landmarks, safe zones for bone resection3-down surgeries in treating insertional Achilles tendinopathies. Methods: Twenty fresh frozen cadavers were selected excluding insertional Achilles tendon pathology on lateral view x-rays. The calcanei were dissected maintaining the Achilles tendon insertion intact. Dimensions of the posterior tuberosity were recorded and marked to plan for three sagittal cuts (medial, middle, and lateral) (Fig 1 A). Using an oscillating saw (Fig 1 B.), the posterior tuberosity was cut into four pieces (Fig 1 C,E). A trapezoid shape (Fig 1 D) was reconstructed demonstrating relative location of the footprints of the Achilles insertion compared to the boundaries of the tuberosity on each piece (A, most superior point in the posterior tuberosity; B, most superior point in the Achilles insertion; C, most inferior point in the Achilles insertion; D, most inferior point in the posterior tuberosity). Data regarding footprints of the Achilles tendon insertion in the sagittal orientation was analyzed and compared within each trapezoid region and among different regions. Results: AB (calcaneal tuberosity tip to the upper limit of the Achilles insertion) was shortest at the medial cut (9.35mm) and longest at the lateral cut (12.15mm). However, the tendon thickness at the insertion (the distance from the proximal to the distal limits) represented by BC was shortest at the lateral cut (13.19mm) and longest at the middle cut (14.04mm). AD, the distance from the highest to the lowest point of the calcaneal tuberosity, was the longest at the middle cut (41.20mm). AB:BC ratio was highest at the lateral cut and lowest at the medial cut, indicating the safe amount of bone to be resected at the Achilles insertion. Tendon thickness relative to the whole calcaneal tuberosity (BC:CD) was highest at the medial wall (Table1). Conclusion: The sagittal orientation and variability of the Achilles tendon insertion is an under-studied topic in the literature. It needs to be addressed given recent trends towards minimally invasive procedures in treating insertional Achilles pathology. This study precisely delineated the footprint in each region of the insertion by creating a trapezoid pattern to compare the coordinates across these areas. This could lead to future three-dimensional reconstruction of the Achilles insertional footprint and patient- specific instrumentation software directed towards optimizing the management of Insertional Achilles pathology.
Should We Fix Them? A Comparison of Outcomes at Mid-Term Follow-Up of Operatively and Non- Operatively Treated Weber B Ankle Fractures
Authors: Ge Laurence , Talusan Paul G , Holmes James , Walton David 
Published: December 2023

Category: Trauma; Ankle Introduction/Purpose: Our group previously presented a novel protocol for non-operative management of Weber B ankle fractures with medial clear space (MCS) < 7mm on gravity stress (GS) radiographs and within 2mm of ipsilateral superior clear space and contralateral GS MCS. The goal of this study is to recruit an operative cohort for comparison of clinical, radiographic, and patient reported outcomes. Methods: We recruited a cohort of patients who may have been considered for the non-operative protocol but underwent surgery instead. Outcome measures were obtained including Kellgren-Lawrence scale for evaluation of arthritis, American Orthopedic Foot & Ankle Society (AOFAS) Hindfoot, Olerud Molander Ankle (OMA), Lower Extremity Functional Scale (LEFS), and PROMIS (physical function, depression, pain interference) scores. This data was then compared to the non-operative cohort. Results: There were 20 patients in the operative cohort and 29 in the original non-operative cohort. Mean follow-up was 6.9 and 6.7 years, respectively. Average outcome scores were as follows for the operative and non-operative groups, respectively: LEFS, 68.1 and 75.2 (p=0.009); OMA, 89.0 and 94.1 (p=0.05); AOFAS, 91.7 and 98.5 (p=0.0003); PROMIS Physical Function, 50.4 and 58.2 (p=0.01); PROMIS Depression, 45.4 and 42.8 (p=0.29); PROMIS Pain Interference, 49.7 and 42.2 (p=0.004). All patients in both groups achieved union of their fracture. There was no difference in Kellgren-Lawrence arthritis scores though interobserver reliability for scoring was poor. In the surgical cohort there were 3 (15%) cases of implant removal, 1 (%) SPN neurapraxia, and 1 (%) delayed wound healing. Conclusion: In carefully selected patients with isolated Weber B fractures and MCS < 7mm on gravity stress radiographs that is within 2mm of ipsilateral superior clear space and contralateral GS MCS, non-operative management may be considered as it can lead to equivalent or superior outcomes with none of the risks typically associated with surgical intervention.
Significant Early Loss of Correction in Modified Lapidus Compared to Original Lapidus for Hallux Valgus
Authors: Acker Antoine , Zainudin Tunko Naziha Tunku , Schauer Elisabeth , Peurière Laura , Reymond Nils , Drittenbass Lisca , Dubois-Ferrière Victor , Assal Mathieu 
Published: December 2023

Category: Bunion; Other Introduction/Purpose: The Lapidus procedure (first tarsometatarsal joint (TMT1) fusion) is an established treatment for correcting hallux valgus with 1st ray hypermobility. The original Lapidus (OL) technique involves fusing the TMT1 joint and first metatarsal base to the second, while the modified Lapidus (ML) technique involves fusing only the TMT1 joint. The purpose of this study was to investigate whether the ML procedure results in an early loss of correction. Methods: This retrospective study analyzed the outcomes of 45 feet in 40 patients with hallux valgus who underwent either the ML (21 feet) or OL (24 feet) procedure between 2014 and 2022 at a single center. All fixations were performed with 3.5 cortical screws, except for 9 cases that were fixed with a plantar locking plate. Differences in the immediate postoperative (6 weeks) and postoperative (6 months) intermetatarsal angle (IMA) and hallux valgus angle (HVA) were analyzed using Mann-Whitney tests, and complications were reported. Results: The mean preoperative IMA and HVA for the OL were 15.8° ± 3.5° and 36.4° ± 9.5°, respectively, and 14.5° ± 2.3° and 33.0° ± 7.0° for the ML. The immediate postoperative IMA and HVA were similar for both procedures (7.2° ± 2.0° and 7.7° ± 4.3° for OL, 7.3° ± 2.1° and 8.5° ± 5.5° for ML). Although from 6 weeks to 6 months postoperatively, the loss of correction of the HVA did not differ between both procedures (4.2° for OL, 5,6° for ML), the IMA loss of correction was significantly higher in the ML (1.1° ± 1.4° vs 0.5° ± 1.1°) (p < 0.05). One case of delayed union was reported in the OL group, but it did not require revision. Conclusion: The study results suggest that the ML procedure does not provide the same stability as the OL procedure in the early postoperative period, as there was a significantly greater early loss of correction of the IMA at 6 months postoperatively in the ML group compared to the OL group. Although there were no differences in the loss of correction of the HVA angle (HVA), an observed loss of 5 degrees remains a concern. Further studies are necessary to better understand the indications of the modified and original procedures.