bluuebunny/crossref_metadata_2025_split huggingface dataset:
Cavovarus with A Twist: Coronal and Axial Plane Rotational Deformity in the Midfoot of Charcot- Marie-Tooth Patients
Authors: An Tonya W. , Haupt Edward T. , Michalski Max , Salo Jari , Pfeffer Glenn B. 
Published: January 2022

Category: Hindfoot; Midfoot/Forefoot Introduction/Purpose: The cavovarus deformity of Charcot-Marie-Tooth (CMT) disease typically presents with hindfoot varus and forefoot valgus. This seemingly paradoxical relationship is poorly understood. Better insight into this complex three- dimensional alignment under physiologic load-bearing conditions is possible using weight-bearing computed tomography (WBCT). This is the first study to examine the extreme rotational deformity in the midfoot of CMT patients, and thereby provides a key to the successful operative correction of the CMT cavovarus foot. Methods: We retrospectively reviewed the WBCTs of patients with CMT who presented to a single surgeon. Those with history of bony surgical correction, severe degenerative joint disease, or open physes in the foot, were excluded. Scans were analyzed using three-dimensional analysis software (Disior Bonelogic) to generate axes of select bones and their relationship relative to the tibial plafond anterior-posterior axis in the axial plane. The coronal alignment of the foot involved angular measurements of the calcaneus, talar dome, midfoot and forefoot relative to the ground. We reported quantitative alignment parameters and compared the measurements to WBCT of 20 controls. Results: 17 WBCT scans from 15 CMT patients (average age 24 years) met criteria for inclusion. In the axial plane, external rotation of the distal tibia accounted for the varus heel position rather than subtalar malalignment. The greatest change in axial alignment occurred between the talar neck and navicular (26 degrees). The average talonavicular (TN) medial uncoverage angle was -15 degrees for CMT patients, indicating medial overcoverage, compared to +11 degrees for controls, (p<0.01). Coronal plane analysis revealed varus rotational deformity at the calcaneus (23 degrees), a peak of 61 degrees varus across the navicular and cuboid, then compensatory rotation of the cuneiforms and metatarsals to achieve a plantigrade forefoot (11 degrees varus). In comparison, controls averaged 9 degrees coronal valgus at the calcaneus and 34 degrees varus at the naviculo-cuboid level, (p<0.01). Figure 1 shows the WBCT scans of a representative CMT patient and control case. Conclusion: This three-dimensional WBCT analysis is the first to characterize and quantify the axial and coronal rotational deformity in CMT. Axial plane deformity had a center of rotational angulation at the talonavicular joint, associated with medial ’overcoverage’ of the talar head, likely from chronic tibialis posterior over-pull. The peak coronal deformity was localized at the navicular and cuboid, which measured nearly twice as much as controls. These observations suggest dorsiflexion osteotomy of the 1st metatarsal would fail to address the coronal rotation; releases through the talonavicular joint may be necessary to abduct and de-rotate the midfoot to achieve a plantigrade foot.
Alignment of the Hindfoot Following Total Knee Arthroplasty: A Systematic Review
Authors: Azam Mohammad , Butler James J. , Mercer Nathaniel P. , Hurley Eoghan T. , Kennedy John G. 
Published: January 2022

Category: Ankle; Hindfoot Introduction/Purpose: The purpose of this systematic review was to evaluate changes in the alignment of the hindfoot following total knee arthroplasty (TKA), subjective clinical outcomes following surgical intervention and to analyze the level of evidence (LOE) and quality of evidence (QoE) of the included studies. Methods: MEDLINE, EMBASE, and Cochrane Library databases were systematically reviewed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies reporting changes in the postoperative alignment of the hindfoot following TKA were included. The level and quality of evidence were recorded and assessed. Results: Eleven studies with a total of 1142 patients (1358 knees) met the inclusion/exclusion criteria. Six studies were of level of evidence II and 5 studies were of level of evidence III. Patients with preoperative varus knee deformity and valgus hindfoot deformity demonstrated improvement in hindfoot alignment post-TKA. Patients with preoperative varus knee deformity and varus hindfoot deformity demonstrated no improvement in hindfoot alignment following TKA. Twelve different radiographic parameters were used to measure the alignment of the hindfoot across the included studies, with the tibio-calcaneal angle (TCA) most frequently utilized (27.3%). Conclusion: This systematic review demonstrated that the hindfoot may display compensatory changes in alignment following total knee arthroplasty in patients with knee osteoarthritis. However, the marked heterogeneity between the included studies and poor quality of evidence limits any meaningful cross-sectional comparisons between studies. Further, well-designed studies are necessary to determine the changes and outcomes of hindfoot alignment following total knee arthroplasty.
Results of Hallux Metatarsophalangeal Joint Arthrodesis with and without Calcaneus Autograft
Authors: Finney Fred T. , Barcel D. , Cohen Bruce E. , Davis W. Hodges , Ellington J. Kent , Irwin Todd A. , Jones Carroll P. 
Published: January 2022

Category: Bunion; Midfoot/Forefoot; Other Introduction/Purpose: Hallux rigidus is the most common degenerative arthropathy of the foot. Primary hallux metatarsophalangeal (MTP) joint arthrodesis is the most common surgical treatment for end-stage hallux rigidus and can also be utilized for correction of hallux valgus. Though satisfaction rates following hallux MTP joint arthrodesis are very favorable, nonunion rates have been reported as high as 12%. Many surgeons use orthobiologics and/or autograft to augment arthrodeses about the foot and ankle in an effort to increase union rates. The purpose of this study is to retrospectively compare union rates of hallux MTP joint arthrodesis with and without calcaneus autograft. Methods: A query of our institution’s administrative database was performed to identify patients who underwent a primary hallux MTP joint arthrodesis between February 2016 and February 2019. We compared patients who underwent arthrodesis with and without calcaneus autograft. Surgeon preference dictated use of autograft, as some in our group routinely use graft while others do not. Patients 18 years and older who underwent a primary hallux MTP arthrodesis were included. Patients were excluded if they had radiographic evidence of significant bone loss or if allograft or biologic therapies were used. Patient charts and final radiographs were reviewed. The primary outcome was successful union of the hallux MTP joint arthrodesis. Secondary outcomes included preoperative diagnosis, type of surgical fixation and surgical complications. Data was compared using a student T-test. Results: There were 336 feet included in the final analysis, and 140 underwent hallux MTP arthrodesis with calcaneus autograft. Mean follow-up time was 14.8 weeks. Among all patients, 89.9% had a successful union. There was no difference in union rates between those who underwent arthrodesis with calcaneus autograft (87.9%) compared to without autograft (91.4%; p = 0.302). Hallux valgus was the preoperative diagnosis in 52.7% of cases followed by hallux rigidus (39.9%). The most common fixation method was a lag screw with a dorsal plate (80.5%). Painful hardware was the next most common complication (8.6%), and smoking and diagnosis of diabetes demonstrated no effect on union rates. In the autograft group, there were no complications related to the calcaneus autograft donor site. Conclusion: As orthobiologics and local bone autograft gain popularity in foot and ankle surgery, it is important to report clinical outcomes and establish evidence-based guidelines for use. In this relatively large retrospective comparison, the use of calcaneal graft was noted to be safe (no complications from graft site). However, there was no difference in union rate when comparing hallux MTP arthrodesis with and without calcaneus autograft.
Minimum 5-Year Outcomes of the Lateral Trabecular Metal Ankle Arthroplasty
Authors: Gagné Oliver , Kim Jaeyoung , Caolo Kristin C. , Ellis Scott J. , Demetracopoulos Constantine A. , Deland Jonathan T. 
Published: January 2022

Category: Ankle; Ankle Arthritis Introduction/Purpose: The treatment of ankle arthritis has changed significantly with the recent advances in total ankle arthroplasty (TAR). Many different designs of TAR have been used around the world as the biomechanical technology advances and our understanding increases. Most implant system are anterior-based and have a flat cut on the tibial prosthesis. Only one implant, the Trabecular Metal (Zimmer-Biomet, Warsaw, IN), utilizes a lateral approach with a fibular osteotomy to gain access to the tibiotalar joint and a sagittally curved tibial component. Recent publications have described a higher reoperation rate with this implant system. This study aimed to report the 5-year clinical and radiographic outcome as well as the survivorship of the implant. Methods: Over a three-year period, two fellowship-trained foot and ankle surgeons used this implant system for patients indicated for TAR. A total of 38 patients were reviewed with an average age of 63.4+-8.6 years-old, BMI of 28.9+-4.6 and the majority (78%) had post-traumatic arthritis. Reoperations and revisions were collected prospectively as part of the local database. Patients participated in surveys preoperatively and at every annual follow-up which included the Foot and Ankle Outcome Score (FAOS). Patients were also evaluated with weightbearing radiographs preoperatively, at the 3 months postoperative and at the 5 year-mark. Those were analyzed by looking at the implant position with validated angles and comparing those over time. Further statistical analysis used paired t-test and Mann-Whitney U test. Results: The survivorship for our cohort was 92% at the 5-year mark. Three patients had the implant extracted at 12 and 15 months postoperative. Two of those patients had revisions to stemmed TARs and one had a below-knee amputation. Reoperations otherwise included 4 fibular hardware removal and 5 medial gutter debridement. As seen in Table 1, the FAOS improved significantly for all domains at 5-year compared to preoperative status. The Pain and Symptoms domains improved above than the MCID. The implant positioning both tibial coronal and sagittal as well as talar sagittal did not significantly change between 3 months and 5 years postoperative. Conclusion: This study describes the use of a laterally based Trabecular Metal TAR with great survivorship (92%) and clinically significant improvement in patient-reported outcomes. The rate of reoperation is higher due to prominent lateral hardware or poorly visualized medial gutters and revisions had to be performed through an anterior approach. Few other studies report 5-year outcomes from this prosthesis. There is a growing need to present more data from different centers to guide its ongoing clinical use.
2021 IFFAS Award for Excellence Winner: Weightbearing Radiographs Reliably Predict Normal Ankle Congruence in Weber B/SER2 and 4a Fractures: A Prospective Case-Control Study
Authors: Gregersen Martin G. , Molund Marius 
Published: January 2022

Category: Ankle; Trauma Introduction/Purpose: In Weber B/SER2-4 ankle fractures assessment with weightbearing radiographs to ascertain stability of the ankle mortise has been advised. However, no previous studies report whether this method leads to preservation of normal ankle congruence in ankles deemed stable. The purpose is to evaluate equivalence of ankle congruence of injured ankles after fracture union versus the uninjured side for stable Weber B/SER2 and partially unstable Weber B/SER4a fracture types. Methods: We conducted a prospective, case-control study of 149 patients with an isolated Weber B fracture demonstrating stability on weightbearing radiographs. All participants were treated nonoperatively with a functional orthosis and full weightbearing allowed. Results from gravity stress radiographs classified ankles as SER2 or SER4a fracture types. We defined an equivalence margin in medial clear space difference of 1.0 millimeters. We also evaluated the reliability of obtaining measurements from weightbearing radiographs. Results: No difference in medial clear space between the injured and uninjured ankle could be observed after fracture union for stable Weber B/SER2 (mean difference 0.1 millimeters, 95% confidence interval -0.3 to 0.0, P =.056) or partially unstable Weber B/SER4a fracture types (mean difference 0.0 millimeter, (95% confidence interval -0.1 to 0.1, P =.797). No between group differences could be observed (mean difference 0.0 millimeter, 95% confidence interval -0.2 to 0.2, P=.842). These findings were consistent with equivalence as the higher limit of the confidence intervals for the differences were less than the predefined equivalence margin. Estimated 95% confidence intervals for the intraclass correlation coefficients indicated excellent inter- and intraobserver reliability. Conclusion: We demonstrated that weightbearing radiographs successfully predict preservation of normal ankle congruence when the weightbearing radiograph is deemed stable. Ankle congruence was equivalent comparing stable Weber B/SER2 and partially unstable Weber B/SER4a fracture types. Excellent reproducibility of the method of obtaining medial clear space measurements was demonstrated.
Automated Volume Measurement of the Syndesmosis Using 3D Weightbearing CT
Authors: Guss Daniel , Lucchese Olivia , Ashkani-Esfahani Soheil , Bhimani Rohan , Waryasz Gregory R. , Kerkhoffs Gino , Lubberts Bart , DiGiovanni Christopher W. 
Published: January 2022

Category: Ankle; Trauma; Other Introduction/Purpose: Recent studies have shown that weight-bearing computed tomography (WBCT) that allows 3D volume measurement of the distal syndesmosis while under physiologic load brings about a higher accuracy in detection of syndesmotic instability, especially if subtle. Since the volume measurement method is complex, time-consuming, and has a noticeable interobserver bias, most clinicians might not still be interested in utilizing it in practice. Automatization of this measurement using computer-assisted methods will not only reduce the interobserver bias but also will be faster and more applicable in practice. This study aimed to develop an automated 3D syndesmosis volume measurement tool using image processing methods and compare the speed and the interobserver bias with human interpreters. Methods: We included 30 patients with subtle syndesmotic instability who had undergone WBCT and were diagnosed intraoperatively. Thirty individuals with otherwise healthy ankles who had WBCT images were allocated to the control group. The volume measurement up to 5cm proximal to the tibial plafond was considered as the most sensitive and specific method to assess syndesmotic stability based on the literature. An algorithm was developed using MATLAB software that could recognize and calculate the syndesmotic volume using WBCT images. The volume measurement method was used by two orthopaedic surgeons for the same population. The time spent by each surgeon and the algorithm was measured. Finally, the values were compared using the t-test; the interobserver correlation coefficient (ICC) was also calculated. P<0.05 was considered statistically significant. Results: The percentage of changes in 3D volume showed a significant difference at 5cm (25.4%; p<0.001), proximal to the tibial plafond. Based on our clinical study, the volume measurement up to 5cm showed a sensitivity of 95.8%, 95%CI:87.8-100, and specificity of 83.3%, 95% CI:68.4-98.2 for detection of syndesmotic instability. The ICC between the clinicians was 75% while using the automated measurement algorithm showed an ICC of 97%. The mean time spent by the clinicians was 268.4+-56.4 and by the algorithm was 2.9+-0.3 seconds (p<0.001, Figure 1). Conclusion: Given the fact that 3D volume measurement of the syndesmosis using WBCT is still a complex technique for most clinicians while it is one of the most accurate diagnostic methods based on recent literature, developing a faster and more accurate method for 3D volume measurement of the syndesmosis leads to a more reliable and easier to use the technique to be used in practice.
Impact of Resilience on Long Term Outcomes of Open Brostrom-Gould Repair
Authors: Lameka Megan , Dib Aseel G. , Andrews Nicholas A. , Torrez Timothy , Rallapalle Vyshnavi , Sinha Tanvee , Shah Ashish 
Published: January 2022

Category: Ankle; Midfoot/Forefoot Introduction/Purpose: The Brostrom-Gould procedure has become known as the gold standard operative procedure for lateral ankle ligament repair. However, little is known about the factors effecting the intermediate outcomes of the Brostrom- Gould repair as measured by new patient reported outcomes instruments and the impact of resilience on post-operative outcomes. This is the first study investigate the impact of resilience on the outcomes of lateral ligament repair. Methods: A retrospective chart review was performed on 173 patients identified using CPT code 27698 who underwent open modified Brostrom Gould lateral ligament repair from Jan 2013 to June 2020. Patient demographics, comorbidities, athletic activities, post op complications as well as co-pathologies commonly seen in CAI were collected. PROMIS Pain Interference v1.1, Physical Function v1.2, and FAAM were collected. Brief Resilience Scale was used to quantify resilience. A linear regression model was constructed to evaluate the independent effect of resilience on each PROMIS and FAAM outcome instrument. Variables were included in the regression model based on an a-priori significance threshold of p<.05 in bivariate analysis. Results: Resilience was found to have an independent effect on all PROMIS and FAAM measures when controlling for the effect of confounding variables. Resilience's effect on outcome measures was as follows: PROMIS physical function (Unstandardized β 8.2, 95% CI 3.9 to 12.6), PROMIS Pain Interference (Unstandardized β -4.8, 95% CI -7.9 to -1.7), FAAM Activity of Daily Living Subscale (Unstandardized β 16.6, 95% CI 8.7 to 24.6), and FAAM Sports Subscale (Unstandardized β 28.4, 95% CI 15.9 to 40.9). Preoperative participation in athletic activities also had a positive independent effect on multiple outcomes metrics including: PROMIS Physical Function (Unstandardized β 9.4, 95% CI 2.8 to 16.0), PROMIS Pain Interference (Unstandardized β -5.3, 95% CI - 10.0 to -.582), and FAAM Sports Subscale scores Interference (Unstandardized β 34.4, 95% CI 15.4 to 53.4). Conclusion: Resilience and patient participation in athletic activities are independent predictors of improved postoperative functional outcomes as measured by PROMIS and FAAM instruments at intermediate term follow-up. Resilient patients and athletes reported significantly higher physical function and less pain burden postoperatively. Furthermore, preoperative quantification of resilience could enable improved prognostication of patients undergoing lateral ligament repair of the ankle.
Dynamic Syndesmotic Stabilisation and Reinforcement of the Antero-Inferior Tibiofibular Ligament with Internal Brace: Early Results and Clinical Outcome
Authors: Lenz Christopher G. , Shepherd David 
Published: January 2022

Category: Ankle; Arthroscopy; Sports; Trauma Introduction/Purpose: Syndesmotic injuries are associated with long recovery times and high morbidity. Systematic reviews show a trend toward better outcomes of dynamic suture buttons compared to screw fixation. Higher rates of malreduction have been reported with screw fixation. The anteroinferior tibiofibular ligament (AITFL) confers the most significant component of translational and rotatory stability. Techniques have developed which reinforce the AITFL. This study aimed to assess results of syndesmotic stabilisation with dynamic stabilisation and reinforcement of the AITFL, with an early mobilisation program. Methods: Retrospective case series of 30 patients (mean age 31 years). Syndesmotic instability was confirmed with clinical examination, MRI and weightbearing-CT. In all cases arthroscopic assessment confirmed the instability intraoperatively and anatomic reduction with an AO clamp was achieved under direct vision. Dynamic syndesmotic stabilisation with a single suture button was performed followed by the placement of an Internal Brace over the AITFL. A standardized postoperative rehabilitation protocol was established. Patients were asked to immediately weight bear in a CAM boot for 6 weeks, commence sagittal Range of Motion (ROM) at 2 weeks, cycling at 4 weeks. At 6 weeks patients continued with full ROM and strengthening, running and cutting at 8 weeks and return to sports at 10 weeks. Foot and Ankle Ability Measure (FAAM) scores were collected postoperatively and outcome of acute and chronic injuries were compared. Results: The average follow-up was 13 months. The total FAAM score for ADL was 95+-4.9% (range, 83 - 100%) and for sport activities 87+-13.6% (range, 50 - 100%). The rating of mean postoperative function for ADL was 94+-5.5% (range, 80 - 100%) and 90+-13% (range, 35 - 100%) for sportv. The difference between acute and chronic injuries was statistically higher (p<0.05) for daily activities and sport, but the rating of current level of sport activites as well as for daily activites did not show a significant difference (p=0.9296 and p=0.1615, respectively). Twenty-seven patients (90%) rated their overall current level of function as normal or nearly normal. Conclusion: This technique aims to directly stabilise the AITFL and the interosseous components of the syndesmosis, and allow early mobilisation and return to sport as early as 10 weeks. Early results show the procedure is safe, with comparable results to the literature. Acute injuries showed better results of the FAAM score than chronic injuries. Long term follow up will address long term outcomes, requirement for removal of devices and how well the Internal brace is tolerated.