bluuebunny/crossref_metadata_2025_split huggingface dataset:
Static vs Dynamic Fixation of Distal Tibiofibular Syndesmosis: A Review of Overlapping Meta-Analyses
Authors: Bernasconi Alessio , Marasco Domenico , Russo Jacopo , Izzo Antonio , Vallefuoco Salvatore , Coppola Francesco , Balato Giovanni , Smeraglia Francesco , Lintz Francois , Patel Shelain 
Published: January 2022

Category: Ankle; Sports Introduction/Purpose: Multiple Level I meta-analyses have been led comparing traditional static vs. more recently-introduced dynamic strategies of fixation for injuries of the distal tibiofibular syndesmosis (TFS). The aim of this review was to assess their robustness and methodological quality, providing support in the choice of a treatment strategy in case of TFS injury using the highest level of evidence. Methods: In this systematic review, conducted in accordance with the PRISMA guidelines, we identified meta-analyses/systematic reviews comparing static and dynamic fixation methods after acute TFS injury. Robustness of studies was evaluated using the Fragility Index (FI) for meta-analysis and the Fragility Quotient (FQ). The risk of bias was evaluated using the Assessment of Multiple Systematic Reviews(AMSTAR) instrument. Finally, the Jadad Decision Algorithm was applied to select the study which provided the highest quality of evidence to develop recommendations for the fixation strategy of these lesions. Results: Out of 1302 records, 4 Level I meta-analyses were included in this study. Analyzing the statistically significant dichotomous outcomes, the median FI was 3.5 (IQR, 2 to 5.5; range, 1 to 9) while the median FQ was 1.9% (IQR, 1 to 3.5; range 0.35 to 4.4). In total, 37% had a FI of 2 or less and 75% of outcomes had a FI of 4 or less. According to the AMSTAR score and Jadad algorithm, the largest meta-analysis was selected as the highest evidence provided so far. Conclusion: We selected the meta-analysis by Grassi et al. as the highest quality provided so far, which found that dynamic fixation reduced complication rates and improved clinical outcomes compared to static methods of fixation. We demonstrated that meta-analyses with statistically significant dichotomous outcomes comparing dynamic and static fixation for treating injuries of the distal tibiofibular syndesmosis are fragile, with a change in less than 4 patients or less than 2% of the study population sufficient to reverse a significant outcome to nonsignificant. Based on these findings, we recommend caution when interpreting the results of these studies.
The Lateral Hook Test: What is the Amount of Force that Should Be Applied to Evaluate Syndesmotic Instability Using Arthroscopy?
Authors: Bhimani Rohan , Lubberts Bart , Hagemeijer Noortje , Zhao John Z. , Saengsin Jirawat , Sato Go , Waryasz Gregory R. , DiGiovanni Christopher W. , Guss Daniel 
Published: January 2022

Category: Ankle; Arthroscopy; Basic Sciences/Biologics Introduction/Purpose: The lateral hook test is considered the gold standard for the diagnosis of coronal plane syndesmotic instability during arthroscopy. The amount of distal tibiofibular space is directly related to the amount of lateral directed applied force. This study aims to determine the optimal amount of forced needed during a lateral hook test to evaluate syndesmotic instability in the coronal plane. The secondary aim was to determine the amount of displacement variation that occurs when the lateral force is angled anteriorly or posteriorly. Methods: Ten fresh-frozen above-knee amputated cadaveric specimens underwent arthroscopic evaluation of the distal tibiofibular joint. The assessment was done first with all syndesmotic and ankle ligaments intact and subsequently with transection of the anterior inferior tibiofibular ligament (AITFL) and the interosseous ligament (IOL). In all scenarios, a lateral hook test was performed under increasing force from 0N to 120N of direct force, with increments of 20N. The lateral hook test was performed in: 1) the neutral position (no angulation), 2) anterior inclination of 15 degrees, and 3) posterior inclination of 15 degrees under the aforementioned force. Anterior and posterior coronal plane distal tibiofibular space were arthroscopically measured. Descriptive statistics were employed to determine the force and the most sensitive method to pull during arthroscopic evaluation to detect syndesmotic instability. Results: Among the specimens, after transection of AITFL and IOL, the anterior and posterior coronal plane space increased with increment in force until 60N and then displayed no change in these measurements despite the increase in force. In the intact state, there was an increase in syndesmosis coronal space with increase in force. Of the three methods of force application, the posteriorly directed force has the largest absolute value for the anterior and posterior coronal space, suggesting it is the most sensitive in distinguishing between stable and unstable syndesmotic injury. Conclusion: Arthroscopic coronal plane evaluation under 60N of direct force is best suited to distinguish stable from an unstable syndesmosis. Syndesmosis anterior and posterior coronal plane space measurement demonstrate the largest absolute difference when subjected to posteriorly directed force, suggesting that this new method of assessment has the highest potential for diagnosing even subtle syndesmotic instability, along with a lower propensity for error.
Prescribing Fewer Opioid Pills to Hallux Valgus Patients Undergoing Minimally Invasive Bunion Correction: A Prospective Comparative Study
Authors: Caolo Kristin C. , Marion Celia , Paugh Rebecca , Johnson A. 
Published: January 2022

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: This study aims to compare opioid usage and patient satisfaction with postoperative pain management in similar hallux valgus (HV) patients who underwent minimally invasive distal chevron akin (MIS) correction with patients who underwent modified Lapidus and scarf corrections. We hypothesized that patients who underwent minimally invasive bunionectomy would consume fewer opioids and report similar satisfaction with pain management compared with modified lapidus and scarf patients. Methods: This study is a single center prospective study of 33 patients diagnosed with hallux valgus undergoing MIS bunion correction who received a novel opioid prescribing protocol used by the senior author. Preoperatively, patients undergoing MIS corrections were counseled on the expectations of pain after surgery, received a take home pamphlet, and were prescribed opioids for moderate surgery (5-15 pills). These patients were then compared to a cohort of 25 hallux valgus patients status post Lapidus or scarf bunionectomy who were prescribed 40-60 opioid pills without preoperative coaching or handouts. Patients were excluded if they used opioids or muscle relaxants preoperatively or had a known history of a substance use disorder. Patients completed surveys postoperatively for eight weeks reporting pain level, number of opioid pills consumed, refill requests, and satisfaction with their pain management plan. Results: There was a significant difference (p< 0.001) in mean pills consumed between MIS patients who averaged 2.5 opioid pills (5mg Oxycodone/pill) and modified Lapidus and scarf patients who averaged 25.2 opioid pills (5mg Oxycodone/pill) at all time points (Table 1). There was no significant difference between the ratio of pills taken to pills prescribed between both groups (p>0.05). Patients had comparable levels of pain at all time points (p>0.05). MIS patients did not request any refills, whereas Lapidus and scarf patients requested a total of 5 refills over the course of the study. Conclusion: HV patients who underwent MIS correction achieved equivalent analgesic effect when compared to similar HV patients who underwent Lapidus or scarf procedures. The Lapidus and scarf group received approximately four times the amount of opioids and consumed 11 times the amount of pills. This study demonstrates that HV patients undergoing MIS bunion correction require far fewer opioid pills to achieve the same level of postoperative pain control compared with Lapidus and scarf patients. This study also suggests that a novel postoperative prescribing protocol utilized by the senior surgeon may decrease the number of pills both prescribed and consumed by patients.
Feasibility of Arthroscopic Anterior Talofibular Ligament Repair and Comparison Between Arthroscopic and MR Findings for Anterior Talofibular Ligament Injuries
Authors: Cho Whi Je , Lee Young Koo 
Published: January 2022

Category: Arthroscopy; Ankle; Arthroscopy Introduction/Purpose: The Modified Broström Operation (MBO) has been frequently used to treat chronic lateral ankle instability. Recent studies of arthroscopic anterior talofibular ligament (ATFL) repair found that if the ligament is detached at the fibular attachment or there is sufficient remnant tissue, it can be directly repaired using suture anchors. In this study, ATFL injuries were classified and the feasibility of arthroscopic ATFL repair according to injury type was determined. The diagnostic validity of magnetic resonance imaging (MRI) of ATFL injuries was investigated by comparing MRI and arthroscopic findings. Methods: The 197 ankles (93 right, 104 left; 12 bilateral) of 185 patients (90 men and 107 women; mean age, 33.5 years, range: 15-68 years) were treated between September 2015 and October 2019. All patients underwent arthroscopic MBO after a diagnosis of chronic lateral ankle instability. ATFL injuries were classified according to their grade and arthroscopically determined location (type 2: partial rupture, type 3A: fibular detachment, type 3B: talar detachment, type 3C: midsubstance rupture, type 3D: absence of ATFL, type 3E: os subfibulare). Two musculoskeletal radiologists blinded to the surgical findings evaluated all of the ankle injuries and classified them as described above. An oblique-coronal MRI sequence was used to improve diagnostic accuracy. Results: The kappa value for interobserver reliability was 0.82 (95% confidence interval [CI], 0.76-0.88), indicating excellent interobserver reliability. The kappa value for the agreement between the arthroscopic findings and MRI findings was also high (0.85; 95% CI, 0.79-0.91). Among the 197 injured ankles, according to ankle arthroscopy, 67 were type 2 (34%), 28 were type 3A (14%), 13 were type 3B (7%), 29 were type 3C (15%), 26 were type 3D (13%), and 34 were type 3E (17%). Conclusion: In this study, arthroscopic ATFL repair was feasible in ~14% of ATFL injuries related to chronic lateral ankle instability. The ATFL classification system proposed herein could help surgeons to determine treatment options before surgery in patients with ATFL injuries, and even evaluate acute injury. Our results also supported the use of MRI for diagnosing ATFL injuries and showed that it is an informative tool during the preoperative period.
Comparison of Midterm Outcomes Between the Intramedullary Fibular Nail and the Locking Plate for the Treatment of Unstable Ankle Fractures in Active Young Patients
Authors: Choi Seung-myung , Cho Byung-Ki 
Published: January 2022

Category: Trauma; Ankle Introduction/Purpose: We aimed to compare the midterm radiological and clinical outcomes between closed reduction and internal fixation (CRIF) using the fibular intramedullary nail (IMN) and open reduction and internal fixation (ORIF) using plates for the treatment of unstable ankle fractures in active young patients. Methods: In this retrospective cohort study, 204 patients treated with CRIF using the fibular IMN (94 patients) or ORIF using the locking plate (110 patients) were included after at least 3 years of follow-up. The mean patient age was 41.4 years. Radiographic evaluation included the quality of reduction assessed by plain radiography and the three-dimensional (3D) reconstruction model using the CT scan images as well as the development of posttraumatic ankle osteoarthritis (PTOA) assessed by weightbearing plain radiography. Clinical evaluation included the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, Olerud and Molander score (OMAS), the Foot and Ankle Outcome Score (FAOS) and visual analog scale (VAS) pain score as well as complications. Results: In an assessment by both plain radiography and the 3D reconstruction model, the fair or poor reduction was more observed in the IMN group than in the ORIF group at final follow-up (P <.001). Poor reduction in the IMN group was significantly related to Weber type C, pronation type injury, and comminuted fibular and trimalleolar fractures (P <.001). PTOA was observed in 21.3% in the IMN group compared to 9.1% in the ORIF group (P =.024). There were no significant differences in clinical outcomes between the 2 groups. There were signiﬁcantly fewer postoperative complications in the IMN group than in the ORIF group (9.5% vs 39%, P <.001). Conclusion: Surgeons should consider ORIF for unstable ankle fractures in active young patients with Weber type C, pronation type injury, and comminuted fibular and trimalleolar fractures.
Risk Factors for Complications Associated with Minimally Invasive Medial Displacement Calcaneal Osteotomy
Authors: Coleman Michelle M. , Thompson John , Bean Bryan , Guyton Gregory P. 
Published: January 2022

Category: Hindfoot Introduction/Purpose: Several minimally invasive medial displacement calcaneal osteotomy (MIS MDCO) techniques have been described utilizing differing methods for creating the osteotomy. However, there are few clinical reports of the safety profile and outcomes after percutaneous MDCO procedures. The purpose of this study was to describe short-term outcomes and complications associated with MIS MDCO for the correction of hindfoot valgus deformities. Methods: A retrospective study was conducted of all patients who underwent consecutive minimally invasive MDCO for the treatment of a hindfoot valgus deformity by a single fellowship-trained foot and ankle orthopaedic surgeon from September 2013 to August 2018. Demographic data, treatment data, and complications were recorded from the electronic medical record for the duration of the patient's follow-up. Univariate statistics were used to determine the relationship between complications and demographic/treatment variables. A p<0.05 was considered significant. Results: Patients who underwent 189 MIS MDCO procedures were included in the study. Median follow-up was 12 months (interquartile range, 7 to 25 months). Osteotomy healing complications were present in 7% of cases. A 12-month cluster of osteotomy healing complications was observed. Healing complication rates were 28% during the cluster and 0.7% outside of the cluster. Osteotomy healing complications were significantly associated with higher American Society of Anesthesiologists (ASA) classification, female sex, current tobacco use, and higher body mass index (BMI). Healing complications were not associated with osteotomy technique (saw vs. burr) or fixation type. Other complications included wound dehiscence (3%), surgical site infection (2%), transient nerve symptoms (6%), and persistent nerve symptoms (2%). Nerve symptoms were significantly associated with an increased number of concomitant procedures. Conclusion: Patients with higher ASA classification, current tobacco use, and higher BMI were at higher risk for osteotomy healing complications after minimally invasive MDCO procedures. Patients were also more likely to develop nerve complications with more extensive surgical procedures. These findings may be useful for surgeons when counseling patients regarding their surgical risks and when optimizing their comorbidities preoperatively.
Talar Osteoperiostic Grafting from the Iliac Crest (TOPIC): Return to Sports Outcomes of A Novel Press-Fit Surgical Treatment for Large Talar Osteochondral Lesions
Authors: Dahmen Jari , Rikken Quinten , Stufkens Sjoerd A. , Kerkhoffs Gino 
Published: January 2022

Category: Ankle Introduction/Purpose: The purpose of this study was to evaluate the sports outcomes of a new press-fit OATS technique for large primary and secondary talar osteochondral lesions of the talus (OLTs), Talar OsteoPeriostic grafting from the Iliac Crest (TOPIC). Methods: The study population included amateur and professional athletes with a talar osteochondral lesion size of at least 10 mm in diameter as measured anteroposteriorly or mediolaterally. The surgical intervention in question was the Talar OsteoPeriostic grafting from the Iliac Crest (TOPIC) procedure, which was performed in a press-fit way. Sports outcomes at a minimum of 24 months included return to sports rates, level (return to any level of sports, return to pre-injury levels of sports, and return to performance), including corresponding return to sports times of the aforementioned levels. Results: A total of 30 athletes, including 1 professional athlete, were assessed. All patients were available for the follow-up at 24 months post-operatively. The mean follow-up duration was 24 months (SD 4.5). The mean lesion size was 356 mm2. Return to any level of sports rate was 90% (95% CI 83 - 95) with an associated time of 8.4 months (SD 2.3). Return to pre-injury level of sports rate was 72% (95% CI 60 - 83) with an associated time of 9.5 months (SD 3.0). Return to performance was 30% (95% CI 20 - 40) with an associated return to performance time of 12 months (SD 4.6). Conclusion: Our study suggests that a TOPIC procedure can be considered a good option in the management of large osteochondral lesions of the talar dome in an active sports population, with adequate return to sports and work outcomes. Further research is required to optimize our surgical technique and show long-term outcomes.
Reduction Quality of Open vs Percutaneous Techniques for the Posterior Malleolus
Authors: Distefano David , Karnyski Steven , Kuhns Benjamin , Ketz John P. , Barra Matthew , Haws Brittany 
Published: January 2022

Category: Ankle; Trauma Introduction/Purpose: Ankle fractures with posterior malleolar involvement are common. Fixation of the posterior malleolus (PM) in these injuries remains controversial & currently, there is no evidence to guide operative decision making for the PM. This study compares radiographic & clinical outcomes between percutaneous & open fixation techniques of the PM. Methods: All ankle fractures between 01/2010 & 01/2018 with surgical stabilization of the PM were reviewed from a level 1 trauma center. High-energy (i.e. pilon), open & pathologic fractures were excluded. Orthopaedic Trauma Association (AO/OTA) fracture pattern, PM articular surface comminution, incarcerated fragments & loose bodies were recorded based on pre-operative CT scans. Patients were either treated with direct reduction (DR) or percutaneous reduction (PR). Intra-operative & serial post- operative radiographs were used to measure PM articular reduction & graded as satisfactory (<2mm articular step-off) or poor (>2mm articular step-off). Medical records were reviewed for fixation technique & complications. Patient-reported outcomes measurement information system (PROMIS) scores were used to compare clinical outcomes. Univariate methods including x2, Fischer exact test, One-way ANOVA were used & a multivariate nominal logistic regression model was constructed to evaluate predictors of a satisfactory reduction. Results: A total of 120 patients (ages 19-84) were included. DR through an open approach was performed in 91 patients & PR in 29. The DR cohort had a higher rate of satisfactory reduction (92.3% vs 75.9%, p=0.04). Articular comminution was identified in 65 (50.4%) & this morphology had a higher rate of satisfactory reduction with ORIF (94% vs 66.6%, p=0.04). There was no difference in reduction quality for non-comminuted fractures treated open or percutaneously (90.2% vs 83.3%, p=0.64). Incarcerated fragments or loose bodies were identified in 58 (48.3%) of fractures. There was a trend for improved reduction quality in the DR group for this morphology (p=0.08). Multivariate analysis identified that open approach is associated with a satisfactory reduction (p=0.02). No difference in complication rate between groups or PROMIS scores (p>0.05) for 64 patients with average final follow up of 19 months (range 6-60 months) were found. Conclusion: This study demonstrates that DR of the PM via an open approach in low energy ankle fractures leads to improved radiographic outcomes compared to percutaneous techniques without a difference in complication rate. This study also highlights the utility of a pre-operative CT scan to better assess the morphology of the posterior malleolus as articular comminution, interposed fragments or loose bodies were common findings that are difficult to assess on plain radiographs & may alter surgical plan if present. However, no difference in PROMIS scores were seen between direct and percutaneous reduction techiniques.
The Routine Use and Cost Analysis of Acid-Fast Bacilli and Fungal Cultures in Foot and Ankle Surgery: A Retrospective Study
Authors: El-Zein Zein S. , Diamond Scott , Bohr Margaret , Baker Erin A. , Fleischer Mackenzie M. , Gehrke Corinn , Fortin Paul T. , Vaupel Zachary M. 
Published: January 2022

Category: Other; Diabetes Introduction/Purpose: Infections pertaining to orthopaedic surgery play a major role in patient morbidity and increased healthcare-associated expenses. In the setting of foot and ankle surgery for infection, it is common practice to send acid-fast bacilli (AFB) and fungal intraoperative cultures, although there is no standard protocol in place. In this study, the rate of positive AFB and fungal cultures and associated costs in a consecutive series of foot and ankle surgeries was retrospectively assessed. Methods: Under an IRB-approved protocol, CPT codes were used to identify 447 procedures in 320 patients, who underwent foot and ankle surgery for infection by fellowship-trained foot and ankle orthopaedic surgeons at a Level 1, private, academic hospital from 2014 to 2019. A medical records review was performed to collect microbiology and patient demographic data. Materials and labor cost data, which was provided by the institution, was used to quantify a total culture cost. Results: In this series, there were 185 male and 135 female patients with an average age of 57 years (range, 10-105) and average BMI of 31 kg/m2 (range, 13-56). No patients had positive AFB cultures and 20 patients (7.5%) had positive fungal cultures. There were 434 AFB and 525 fungal cultures performed during these procedures. Based on total cultures performed, there were 0% (0/434) AFB and 5% (26/525) fungal culture positivity rates. The total intra-institutional cost (i.e. labor and materials) for AFB cultures was $23,967. The total labor/materials cost for negative and positive fungal cultures was $12,428 and $2,371, respectively. The total labor/materials cost for all the cultures obtained over the time frame of our study was $38,767. Conclusion: This study highlighted low rates of positive AFB and fungal cultures in the orthopaedic foot and ankle surgery service in a 6-year retrospective review, as well as substantial institutional costs of routine use of intraoperative cultures. While this series included cases from three fellowship-trained foot and ankle orthopaedic surgeons, this study will be expanded to analyze AFB and fungal culturing practices and cost in other orthopaedic subspecialties. Creating and implementing a standardized protocol may achieve cost effectiveness of cultures without diminishing patient outcomes.