bluuebunny/crossref_metadata_2025_split huggingface dataset:
Considering the Normal Tibial Values of Axial Rotation in Adults for Deformity Correction Osteotomies and Post-Operative Evaluation of Complex Tibial Fractures
Authors: Clarke Gonzalo Fernandez , Morales Eduardo Fuentes , Cataldo Mauricio , Duran Humberto , Pacheco Florencia 
Published: January 2022

Category: Trauma; Other Introduction/Purpose: Tibial torsion has been mainly analyzed in pediatric deformities of lower limbs. Nevertheless this parameter has acquired relevancy in treatment of rotational deformities in adult population, that require axial correction. There are few articles that report normal values of tibial torsion, mostly in children, parameter that must be corrected in deformities to improve long term outcomes. Normal values in our population need to be established for preoperative planning and corrections. Our objective is to establish a normality parameter of tibial torsion in adults, that helps us in surgical planning of tibial rotational mal alignment and evaluation of the postoperative axial axis in complex tibial fractures. Methods: Descriptive study. We analyzed 18 computed tomography of 18 patients (35 tibias), through the Horos v.3.3.5 program, specifically in the 3D curved-MPR. Inclusion criteria: adult patients, without prior knee, leg or ankle deformities, without post-traumatic sequelae of the limb. Exclusion criteria: severe osteoarthritis of the knee or ankle, presence of osteosynthesis material in the limb, presence of previous osteotomies. Measurements were performed in standardized form previously defined by two foot and ankle orthopedic surgeons. We establish the comparison between both legs of each patient to determine posible variability and measurement interobserver correlations through kappa values. Results: All continuous variables are reported as means +- standard deviations. Student t-test was performed for continuous variables depending on the normality of the data distribution. We also performed de paired t-test to identify any significant differences in left and right tibial measurements. Statistical analyses were carried out by an independent statistician using Stata 16 statistical software. Measurements were performed establishing parameters in axial cuts of the tibia and overlapping two images previously determined. 18 patients (35 tibias) were measured, one limb was deleted for severe compromise the tibial plafond by osteoarthritis. 15 male and 3 female patients with an average of 65 years old (62-76 years). Mean external rotation of the distal tibial was 33° (16.1°-49.8°), difference between left and right tibias was in mean values of 1.95°, not being considered statistically significant. Interobserver correlation was reported at 97% in left tibia and 98% in the right, by intraclass correlation. Conclusion: Tibial torsion is an important component when correcting tibial axial deformities in adults. Our study shows higher normal values than the ones reported in current literature, but it is important to mention that the best parameter of evaluation is the comparison with the contralateral extremity of each patient.
How Has Opioid Prescribing in Total Ankle Arthroplasty Changed with Time and State Legislation? A National and State-Level Analysis
Authors: Cunningham Daniel J. , Wixted Colleen , Allen Nicholas B. , Hanselman Andrew , Adams Samuel B. 
Published: January 2022

Category: Ankle; Ankle Arthritis Introduction/Purpose: Total ankle arthroplasty (TAA) is an increasingly-utilized treatment for ankle arthritis, and opioids are commonly used as part of perioperative pain control. However, many states have enacted opioid-limiting legislation to reduce perioperative opioid prescribing. The aim of this study was to evaluate the impact of time and state legislation on perioperative opioid prescribing in TAA. Methods: This study is a retrospective, observational review of 90-day perioperative opioid prescribing in 1,829 patients undergoing TAA throughout the United States using a large insurance database. Initial and cumulative volumes and rates of opioid prescription filling were recorded along with baseline patient and operative characteristics. Dates of state legislation enactment were also recorded. Student t-tests, analysis of variance (ANOVA), and multivariable linear and logistic regression were utilized to analyze the impact of time and state legislation on opioid prescription filling. Results: In the 90-day perioperative time period, initial and cumulative opioid prescription filling in oxycodone 5-mg equivalents has decreased significantly from 2010 (63.8 initial and 163.3 cumulative oxycodone 5-mg equivalents filled) to 2019 (41.1 initial and 67.2 cumulative oxycodone 5-mg equivalents filled). States with opioid-limiting legislation saw larger and more significant reductions in initial and cumulative opioid prescription filling pre-act to post-act (63.3 to 50.6 oxycodone 5-mg equivalents filled with legislation vs 61.4 to 51.9 oxycodone 5-mg equivalents filled without legislation initial and 146.4 to 93.3 oxycodone 5-mg equivalents filled with legislation vs 125.1 to 108.6 oxycodone 5-mg equivalents filled without legislation cumulative). Conclusion: This study demonstrates that orthopaedic surgeons in states with opioid-limiting legislation have responded by significantly reducing 90-day perioperative opioid prescribing in TAA. These results encourage states without legislation to enact opioid-specific laws to reduce opioid prescribing.
Regional Anesthesia Decreases Early Perioperative Opioid Demand but Increases Late Opioid Demand in Ankle and Distal Tibia Fracture Surgery
Authors: Cunningham Daniel J. , Paniagua Ariana , DeLaura Isabel , Zhang Gloria X. , Kim Billy I. , Kim Jonathan , Lee Terry , LaRose Micaela , Adams Samuel B. , Gage Mark 
Published: January 2022

Category: Ankle; Trauma Introduction/Purpose: Regional anesthesia (RA) is commonly used in ankle and distal tibia surgery. However, the pragmatic effects of this treatment on inpatient and outpatient opioid demand are unclear. The hypothesis was that RA would decrease inpatient opioid consumption and have little effect on outpatient opioid demand in patients undergoing ankle and distal tibia fracture surgery. Methods: All patients ages 18 and older undergoing ankle and distal tibia fracture surgery at a single institution between 7/2013 and 7/2018 were included in this study (n=1,310). Inpatient opioid consumption (0-72 hours post-operative) and outpatient opioid prescribing (1-month pre-operative to 90-days post-operative) were recorded in oxycodone 5-mg equivalents (OE's). Adjusted models were used to evaluate the impact of RA on inpatient and outpatient opioid demand. Results: Adjusted models demonstrated decreased inpatient opioid consumption in patients with RA (12.1 estimated OE's without RA vs 8.8 OE's with RA from 0-24 hours post-op, p<0.001) but no significant difference after that time (9.7 vs 10.4 from 24-48 hours post-op, and 9.5 vs 8.5 from 48-72 hours post-op). Estimated cumulative outpatient opioid demand was significantly increased in patients receiving RA at all timepoints (112.5 OE's without RA vs 137.3 with RA from one-month pre-op to two- weeks, 125.6 vs 155.5 OE's to 6-weeks, and 134.6 vs 163.3 OE's to 90-days, all p-values for RA <0.001). Figure demonstrates a histogram of the inpatient opioid consumption in patients with and without RA. Conclusion: In ankle and distal tibia fracture surgery, RA was associated with decreased early inpatient opioid demand but significantly increased outpatient opioid demand after adjusting for baseline patient and treatment characteristics. These findings provide information on the real-world impact of RA and temper enthusiasm for perioperative nerve blockade.
State Regulation Positively Impacts Opioid Prescribing Patterns in Ankle Fracture Surgery: A National and State-Level Analysis
Authors: Cunningham Daniel J. , Blatter Michael , Adams Samuel B. , Gage Mark 
Published: January 2022

Category: Ankle; Trauma Introduction/Purpose: The impact of time and state regulation on opioid prescribing in orthopaedic trauma is not well known. The purpose of this study is to evaluate the impact of time and state-level opioid legislation on 90-day perioperative opioid prescribing in ankle fracture surgery from 2010 - 2019. Methods: This is a retrospective, cohort study using a national insurance database including commercial insurance, Medicare, Medicaid, and cash pay patients to evaluate 90-day perioperative opioid prescription filling in 40,286 patients ages 18 and older undergoing Current Procedural Terminology codes 27766, 27769, 27792, 27814, 27822, and/or 27823 between 2010 and 2019 in all 50 United States. The primary study outcome was initial and cumulative 90-day perioperative opioid prescription filling and rates of filling and refills. Results: Mean first prescription volume has not changed dramatically from 2010 (37 oxycodone 5-mg pills) to 2019 (33.3 oxycodone 5-mg pills). However, cumulative prescriptions within the 90-day perioperative timeframe have decreased considerably from 2010 (128.5 oxycodone 5-mg pills) to 2019 (70.4 oxycodone 5-mg pills, p<0.001), and cumulative prescription filling in years 2018 and 2019 was significantly less than in 2010. Legislation targeting duration or duration and volume had the largest impacts on initial and cumulative opioid prescribing (approximately 14-22 fewer oxycodone 5-mg pills filled in states with legislation compared to states without legislation, p<0.001). The figure shows state-level pre-act and post-act cumulative 90-day opioid prescribing in ankle fracture surgery. Conclusion: In ankle fracture surgery, cumulative opioid prescribing has decreased dramatically over time. In addition, states with opioid prescribing legislation had larger reductions in perioperative opioid prescribing compared to states without opioid legislation. Legislation targeting duration or duration and volume had the largest impacts on opioid prescribing.
The Incidence of Osteochondral Lesions after Isolated Syndesmotic Injury: A Systematic Review and Meta-Analysis
Authors: Dahmen Jari , Stufkens Sjoerd A. , Kennedy John G. , Kerkhoffs Gino 
Published: January 2022

Category: Ankle Introduction/Purpose: To determine the incidence of osteochondral lesions of the ankle (as well as their location and size) incidence after isolated syndesmotic injuries. Methods: A literature search was performed to identify studies published using PubMed (MEDLINE), EMBASE, CDSR, DARE, and CENTRAL. Two authors separately and independently screened the search results and conducted the quality assessment using the MINORS criteria. Available full-text studies published in English, Dutch and German were eligible for inclusion. OCL incidence as well as location after isolated syndesmotic injuries were extracted from the original articles and subsequently pooled. Whenever possible, OCL incidence per syndesmotic timing (Acute/subacute/chronic) was calculated, pooled and compared with a random effects model. Results: Nine articles were included with 694 syndesmotic injuries. Overall (O)CL incidence was 21.6% (95% CI 18.7 - 24.8%). This rate was 15.9% (95% CI 12.2 - 20.4), 11.4% (95% CI 5.9 - 21.0), and 54.2% (95% CI 44.2-63.8) for the acute, sub-acute, and chronic isolated syndesmotic group, respectively, thereby showing a significant difference in incidence rate between the acute and chronic syndesmotic injuries group (p<0.05). Concerning overall (O)CL incidence, 74.6% (95% CI 65.9 - 81.2) of the lesions were located on the talar dome and 16.7% (95% CI 10.9 - 24.6%) of the lesions were located on the distal tibia (p<0.05). (O)CL size was not reported in any of the studies. Concerning location difference between the acute and chronic group, the incidence of talar (O)CLs was higher in the acute group than in the chronic group (100% 95% CI 93.9 - 100% vs. 46.8% 95% CI 33.3 - 60.8%.) (p<0.05). Conclusion: This meta-analysis showed that (osteo)chondral lesions of the ankle are frequently associated with isolated syndesmotic injuries. (O)CL incidence was significantly higher in the chronic isolated syndesmotic injuries group compared to the acute group (54% versus 16%). The vast majority of (O)CLs were located on the talar dome.
Homolateral Lisfranc Fracture/Dislocation of 1st - 5th Metatarsals in a Collegiate Quarterback: A Case Study
Authors: Dayton Steven R. , Krautmann Kurt M. , Boctor Michael , Tjong Vehniah K. , Kadakia Anish R. 
Published: January 2022

Category: Sports; Midfoot/Forefoot Introduction/Purpose: Lisfranc injuries encompass a spectrum of injuries to the tarsometatarsal (TMT) joint complex from ligamentous sprains to fractures with dislocation. While studies have shown it is possible to return to sport (RTS) after low- energy injuries, no literature exists demonstrating RTS after homolateral fracture/dislocation of all 5 metatarsals. We present a novel surgical technique for repair of homolateral Lisfranc fracture/dislocation of the 1st-5th metatarsals. Fusion of the 2nd and 3rd TMT joints provides stability of the middle column. Internal bracing of the 1st TMT joint gives stability while preserving greater physiologic motion in a high-level athlete. Methods: A dorsal approach is used for fusion of the 2nd and 3rd TMT joints with medial approach for internal bracing of the 1st TMT joint. 2nd and 3rd metatarsals were denuded of cartilage, and the fusion site was fully prepared. Rigid fixation was applied to the fusion sites. Guidewire for the cannulated Internal Brace system is inserted into the base of the 1st metatarsal. Fluoroscopic imaging confirmed positioning and the 3.4mm drill is passed over the wire, followed by the cannulated tap. A 4.75mm Swivelock anchor with Fibertape suture is inserted into the metatarsal base. The guidewire is placed in a reciprocating position on the medial cuneiform. The 2.7 mm drill is passed over the wire, followed by the 3.5 mm tap. A 3.5 mm Swivelock is then loaded with the Fiberwire from the 1st metatarsal. Tensioning is performed, and the 3.5 mm Swivelock is inserted into the medial cuneiform. Results: The athlete was cleared to return to full competition 9 months following surgery with physical exam demonstrating stability in both dorsiflexion and abduction. Weight bearing x-rays showed no evidence of hardware failure and no instability in the 1st TMT joint. CT scan demonstrated solid fusion of 2nd and 3rd TMT joints and maintained anatomic reduction of the 1st TMT joint. At 1-year post-op, patient was having pain over the 4th TMT joint. He had a second surgery to remove an exostosis at the 4th TMT joint as well as remove the screw from the 3rd metatarsal to the middle cuneiform. His pain had resolved at most recent follow up. He returned to game action in the final game of his senior season. Conclusion: The literature demonstrates return to sport is possible for athletes with Lisfranc injuries though the data focuses on either purely ligamentous injuries or Myerson type B and C fractures. This case study demonstrates a novel surgical approach to homolateral fracture/dislocation. While return to sport in this athlete took longer than lower-energy injuries, it is possible for athletes with homolateral displacement to return to full competition.
Does BMI Effect Intermediate Outcomes of Open Brostrom-Gould Repair?
Authors: Dib Aseel G. , Andrews Nicholas A. , Torrez Timothy , Pate James , Ozimba Kalah , Jacob Roshan , Harrelson Whitt , Naranje Sameer , Shah Ashish 
Published: January 2022

Category: Ankle; Midfoot/Forefoot Introduction/Purpose: High BMI is a known risk factor for development of CAI and intraarticular pathology, but few studies have examined BMI's impact of the outcomes of lateral ligament reconstruction. The open Brostrom-Gould reconstruction, an anatomic repair, is the gold standard for repair of the lateral ligamentous complex. We aim to evaluation the impact of BMI on patient reported outcomes after open Brostrom-Gould repair. Methods: A total of 201 patients who underwent open Brostrom-Gould Repair were identified using CPT code. Patients undergoing repair for acute ligamentous injury were excluded. A completed telephonic survey was required for inclusion yielding 92 patients. The telephone survey included: PROMIS Physical Function (PF), Pain Interference (PI), and Depression domains(D) and the Foot and Ankle Ability Measure (FAAM). Medical records were examined for patient characteristics, operative variables, and complications. Patients were grouped by BMI <30 and BMI >30. Results: A total of 28 males (30%) and 61 females (69%) were including in this study. The average time at completion of survey was 4.1 years (standard deviation of 2.8). The median age was 44 with an interquartile range (IQR) of 20, while the median BMI was 31.5 with an IQR of 13.4. Obese patients had significantly worse PROMIS PF (Median 44.5 IQR 7.4 vs median 48 IQR 16.5) and FAAM Activity of Daily Living subscale scores (Median 61.6 IQR 30.0 vs. median 82.7 IQR.36). Patients' FAAM self-reported overall level of function was significantly lower in obese patients (Median 70.0 IQR 20.0 vs median 85 IQR 29). The BMI groups did not vary by other PROMIS domains or FAAM subscales. Conclusion: At intermediate term follow-up, Obese patients report significantly worse physical function after open Bostrom- Gould repair compared to non-obese patients. Surgeons should be aware of this when prognosticating the outcomes of anatomic ankle reconstruction.
Acute Achilles Tendon Rupture, A More Cost-Effective Surgical Technique Option: Dresden-Calcaneal Tunnel
Authors: Enríquez Gonzalo , Escudero Mario I. , Pellegrini Manuel J. , Nuñez Alfredo 
Published: January 2022

Category: Sports; Ankle Introduction/Purpose: Surgical treatment remains the standard of care for active patients with acute midsubstance Achilles tendon ruptures. Clinical decisions must be made, often under circumstances of limited resources. The objective of our study was to describe a reduced cost minimally invasive surgical technique. The use of suture anchor increases the tensile strength of the repair, allowing to prevent tendon lengthening and re-ruptures during early rehabilitation, but these present a high cost and are not exempt from complications such as pullout, local irritation and bone edema. A simple and low-cost alternative that allows us to replace the function of the anchors is to drill a bone tunnel in the calcaneus and pass a high-resistance suture through it. Methods: After obtaining IRB approval, a retrospective review of 12 patients with acute Achilles tendon rupture treated with the modified Dresden-Calcaneal Tunnel technique, between January 2019 and August 2020 and followed up for 6 months. Clinical outcome was assessed using the AOFAS, FAOS and SF-36 scores. Complications, and time to return to work and light sport activity were assessed. Results: The AOFAS score was 94 +/- 5, FAOS 95% +/- 2 and SF-36 92 +/- 4 at 6 months postoperatively. The recovery time of the patients was 10-18 weeks. The postoperative recovery time to exercise was 16-24 weeks. There was only 2 cases with discomfort in relation to the suture knot near to the calcaneal tunnel, but both case refers spontaneous relief at the second month postoperative. Conclusion: This new and minimally invasive technique could be a more cost-effective option in the management of acute Achilles tendon rupture with good functional outcomes. These strategy presents a low occurrence of complications, permit a strong fixation, avoid sural nerve entrapment and respect the biologic environment.
Retrospective Chart Review: Weight Bearing CT Scans and the Measurement of the Lisfranc Ligamentous Complex
Authors: Falcon Spencer , McCormack Thomas J. , Mackay Matthew , Tarakemeh Armin , Mullen Scott , Schroeppel Paul , Wolf Megan R. , Vopat Bryan G. 
Published: January 2022

Category: Midfoot/Forefoot Introduction/Purpose: Lisfranc Ligamentous Complex injuries are commonly misdiagnosed due to their unreliable projection on plain films. Many studies have striven to establish baseline measurements of the frequently injured articulations. While cadaver, MRI, ultrasound, and non-weight bearing computer tomography (CT) have been utilized, weight bearing CT (WBCT) scans are a relatively new imaging modality that has not yet been utilized to establish reproducible and widely-referenced baseline anatomic positions. The hyoptheses of this study are: 1. Standing, weight bearing CT scan will allow for evaluation and measurement of the Lisfranc joint complex. 2. There will be no side to side variation or sex-based differences in the Lisfranc joint complex. Methods: A retrospective chart review was conducted using the electronic medical record. Inclusion criteria was applied as follows: patients who have undergone weight bearing CT of the bilateral lower extremities from 2018 to 2020. One hundred twelve foot CT scans were acquired for measurements. Measurements were collected by two independent reviewers twice in order to achieve inter- and intra-reliability. The measurements were then analyzed in order to establish a baseline for normal anatomy, compare injured to non-injured side, and observe any sex-based differences. Results: Measurements of uninjured legs were utilized to define normal parameters for Lisfranc ligamentous complex (LLC) injuries. Averages were found for measurements of base 1 to 2 MT 2.7mm (SD=0.7mm), medial cuneiform to 2nd MT [M2-C1] 3.7mm (SD=0.7mm), intercuneiform distance 1.2mm (SD=0.3mm), sagittal descent 12.2mm (SD=5.4mm).Patient's with injury to LLC had a larger base of M1-M2, distance from base of first metatarsal to base of second metatarsal (Δ=.5903, p <.0001) and M2- C1 interval (Δ=1.8008, p<0.0001). Males had significantly higher M2-C1 (p=0.0031), intercuneiform distance (p=0.0039), and sagittal descent (p=0.0008) compared to female patients.No significant differences were found with regard to left vs right side in any of the measurements. Intercuneiform distance (p=0.0039) was found to significantly decrease as age increased, while sagittal descent significantly increased with increased age (p=0.0066). Conclusion: This study is one of the first investigations aims to assist in defining baseline anatomic measurements for Lisfranc ligamentous complex parameters on WBCT. The values and comparisons obtained were able to reinforce that weight bearing CT is valuable in identifying subtle injuries to the LLC while also demonstrating that there is male-to-female and age-related differences that should be kept in mind when radiographically evaluating imaging studies of injured patients.