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Foot & Ankle International
Journal Prestige (SJR): 1.626
Citation Impact (citeScore): 3
Number of Followers: 11  
 
  Hybrid Journal Hybrid journal (It can contain Open Access articles)
ISSN (Print) 1071-1007 - ISSN (Online) 1944-7876
Published by Sage Publications Homepage  [1166 journals]
  • Letter Regarding: Risk Factors for Anterior Tibial Tendon Pathology

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      Authors: Andrew D. Beischer
      Pages: 1366 - 1366
      Abstract: Foot & Ankle International, Volume 42, Issue 10, Page 1366-1366, October 2021.

      Citation: Foot & Ankle International
      PubDate: 2021-10-13T12:00:38Z
      DOI: 10.1177/10711007211036083
      Issue No: Vol. 42, No. 10 (2021)
       
  • Response to “Letter Regarding: Risk Factors for Anterior Tibial
           Tendon Pathology”

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      Authors: Matthew M. Levitsky, Christina E. Freibott, Justin K. Greisberg, J. Turner Vosseller
      Pages: 1367 - 1367
      Abstract: Foot & Ankle International, Volume 42, Issue 10, Page 1367-1367, October 2021.

      Citation: Foot & Ankle International
      PubDate: 2021-10-12T11:58:34Z
      DOI: 10.1177/10711007211036085
      Issue No: Vol. 42, No. 10 (2021)
       
  • Education Calendar

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      Pages: 1368 - 1368
      Abstract: Foot & Ankle International, Volume 42, Issue 10, Page 1368-1368, October 2021.

      Citation: Foot & Ankle International
      PubDate: 2021-10-12T11:52:15Z
      DOI: 10.1177/10711007211050418
      Issue No: Vol. 42, No. 10 (2021)
       
  • Comparison of Computed Tomography, Traction, and Inverted Grayscale
           Radiographs for Understanding Pilon Fracture Morphology

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      Authors: Gokay Eken, Abdulhamit Misir
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:There have been no studies evaluating the usefulness of grayscale radiographs in extremity fractures. We aimed to compare the ability and reliability of traction radiographs vs traction grayscale inversion radiographs to detect fracture fragment and comminution zones in comminuted tibia pilon fractures.Methods:Plain radiographs and grayscale inversion images of 60 patients with Orthopaedic Trauma Association/AO Foundation type C3 fracture were evaluated by 20 observers (15 orthopedic surgeons and 5 radiologists) after traction had been applied. The anterolateral, posterolateral, and medial malleolar fragments, as well as the lateral, central, and medial column comminution zones, were identified by all physicians. Computed tomography scan images were used as the “gold standard” against which plain radiographs and grayscale inversion image interpretation were measured. Intra- and interobserver reliability and correct identification of fracture fragments and comminution zones were evaluated.Results:The interobserver reliability for 3 of the fracture fragments and comminution zones on the traction plain radiographs was moderate, whereas it was substantial on traction grayscale inversion radiographs. The lateral comminution zones (P = .001) and presence or absence of posterolateral fragments (P < .001) were significantly better identified in grayscale inversion radiographs compared to standard radiographs.Conclusion:After traction was applied, we found grayscale inversion radiographs are superior to plain radiographs in the identification of posterolateral fragment and lateral zone of comminution in comminuted intraarticular pilon fractures.Level of Evidence:III, Retrospective Case Series.
      Citation: Foot & Ankle International
      PubDate: 2021-10-12T11:46:17Z
      DOI: 10.1177/10711007211049247
       
  • Assessment of Progressive Collapsing Foot Deformity Using Semiautomated 3D
           Measurements Derived From Weightbearing CT Scans

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      Authors: Nicola Krähenbühl, Peter Kvarda, Roman Susdorf, Arne Burssens, Roxa Ruiz, Alexej Barg, Beat Hintermann
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:In progressive collapsing foot deformity (PCFD), hind- and midfoot deformities can be hard to characterize based on weightbearing plain radiography. Semiautomated 3-dimensional (3D) measurements derived from weightbearing computed tomography (WBCT) scans may provide a more accurate deformity assessment. In the present study, automated 3D measurements based on WBCT were used to compare hindfoot alignment of healthy individuals to patients with PCFD.Methods:The WBCT scans of 20 patients treated at our institution with either a flexible (N = 10) or rigid (N = 10) PCFD were compared with the WBCT scans of a control group of 30 healthy individuals. Using semiautomated image analysis software, from each set of 3D voxel images, we measured the talar tilt (TT), hindfoot moment arm (HMA), talocalcaneal angle (TCA; axial/lateral), talonavicular coverage (TNC), and talocalcaneal overlap (TCO). The presence of medial facet subluxation as well as sinus tarsi/subfibular impingement was additionally assessed.Results:With the exception of the TCA (axial/lateral), the analyzed measurements differed between healthy individuals and patients with PCFD. The TCA axial correlated with the TNC in patients with PCFD. An increased TCO combined with sinus tarsi impingement raised the probability of predicting a deformity as rigid.Conclusion:Using 3D measurements, in this relatively small cohort of patients, we identified relevant variables associated with a clinical presentation of flexible or rigid PCFD. An increased TCO combined with sinus tarsi impingement raised the probability of predicting a deformity as rigid. Such WBCT-based markers possibly can help the surgeon in decision-making regarding the appropriate surgical strategy (eg, osteotomies vs realignment arthrodesis). However, prospective studies are necessary to confirm the utility of the proposed parameters in the treatment of PCFD.Level of Evidence:Level III, case-control study.
      Citation: Foot & Ankle International
      PubDate: 2021-10-07T02:16:09Z
      DOI: 10.1177/10711007211049754
       
  • Intra-Articular Synovial Fluid With Hematoma After Ankle Fracture Promotes
           Cartilage Damage In Vitro Partially Attenuated by Anti-Inflammatory Agents
           

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      Authors: Nicholas B. Allen, Bijan Abar, Richard M. Danilkowicz, Virginia B. Kraus, Steven A. Olson, Samuel B. Adams
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:Intra-articular ankle fracture (IAF) causes posttraumatic osteoarthritis (PTOA), but the exact mechanism is unknown. Proinflammatory mediators have been shown to be present in the synovial fluid fracture hematoma (SFFH) but have not been linked to cartilage damage. The purpose of this study was to determine if the SFFH causes cartilage damage and whether this damage can be attenuated by commercially available therapeutic agents.Methods:Synovial fluid was obtained from 54 IAFs and cultured with cartilage discs from the dome of fresh allograft human tali and randomly assigned to one of the following groups: (A) control—media only, (B) SFFH from days 0 to 2 after fracture, (C) SFFH from days 3 to 9, (D) SFFH from days 10 to 14, (E) group B + interleukin 1 receptor antagonist (IL-1Ra), and (F) group B + doxycycline. The cartilage discs underwent histological evaluation for cell survival and cartilage matrix components. The spent media were analyzed for inflammatory mediators.Results:Cartilage discs cultured with SFFH in groups B, C, and D demonstrated significantly increased production of cytokines, metalloproteinases (MMPs), and extracellular matrix breakdown products. Safranin O staining was significantly decreased in group B. The negative effects on cartilage were partially attenuated with the addition of either IL-1RA or doxycycline. There was no difference in chondrocyte survival among the groups.Conclusion:Exposure of uninjured cartilage to IAF SFFH caused activation of cartilage damage pathways evident through cartilage disc secretion of inflammatory cytokines, MMPs, and cartilage matrix fragments. The addition of IL-1Ra or doxycycline to SFFH culture partially attenuated this response.Clinical Relevance:IAFs create an adverse intra-articular environment consisting of significantly increased levels of inflammatory cytokines and MMPs able to damage cartilage throughout the joint. These data suggest that the acute addition of specific inflammatory inhibitors may decrease the levels of these proinflammatory mediators.
      Citation: Foot & Ankle International
      PubDate: 2021-10-07T02:15:58Z
      DOI: 10.1177/10711007211046952
       
  • Association of First Metatarsal Pronation Correction With Patient-Reported
           Outcomes and Recurrence Rates in Hallux Valgus

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      Authors: Matthew S. Conti, Tamanna J. Patel, Jiaqi Zhu, Andrew J. Elliott, Stephen F. Conti, Scott J. Ellis
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:The purpose of this study was to determine if a postoperative decrease in first metatarsal pronation on 3-dimensional imaging was associated with changes in patient-reported outcomes as measured by the Patient-Reported Outcomes Measurement Information System (PROMIS) physical function, pain interference, and pain intensity domains or recurrence rates in patients with hallux valgus (HV) who undergo a first tarsometatarsal fusion (modified Lapidus procedure).Methods:Thirty-nine consecutive HV patients who met the inclusion criteria and underwent a modified Lapidus procedure had preoperative and ≥2-year postoperative PROMIS scores and had first metatarsal pronation measured on preoperative and at least 5-month postoperative weightbearing CT scans were included. Multivariable regression analyses were used to investigate differences in the change in PROMIS domains preoperatively and 2 years postoperatively between patients with “no change/increased first metatarsal pronation” and “decreased first metatarsal pronation.” A log-binomial regression analysis was performed to identify if a decrease in first metatarsal pronation was associated with recurrence of the HV deformity.Results:The decreased first metatarsal pronation group had a significantly greater improvement in the PROMIS physical function scale by 7.2 points (P = .007) compared with the no change/increased first metatarsal pronation group. Recurrence rates were significantly lower in the decreased first metatarsal pronation group when compared to the no change/increased first metatarsal pronation group (risk ratio 0.25, P = .025).Conclusion:Detailed review of this limited cohort of patients who underwent a modified Lapidus procedure suggests that the rotational component of the HV deformity may play an important role in outcomes and recurrence rates following the modified Lapidus procedure.Level of Evidence:Level III, retrospective cohort study.
      Citation: Foot & Ankle International
      PubDate: 2021-10-06T02:48:44Z
      DOI: 10.1177/10711007211046938
       
  • Third-Generation Minimally Invasive Chevron-Akin Osteotomy for Hallux
           Valgus Produces Similar Clinical and Radiological Outcomes as Scarf-Akin
           Osteotomy at 2 Years: A Matched Cohort Study

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      Authors: Adriel You Wei Tay, Graham S. Goh, Kevin Koo, Nicholas Eng Meng Yeo
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:The minimally invasive chevron-Akin (MICA) osteotomy is an increasingly popular technique for the correction of hallux valgus. However, there is a paucity of literature comparing it with traditional open techniques. The purpose of this study was to compare the clinical and radiological outcomes of the MICA osteotomy using a new-generation MICA screw and scarf-Akin osteotomy for hallux valgus correction.Methods:Thirty cases of MICA osteotomy were propensity score matched 1:1 with a control group of 30 scarf-Akin osteotomy cases. The groups were matched for age, sex, body mass index, preoperative visual analog scale (VAS) score, American Orthopaedic Foot & Ankle Society (AOFAS) metatarsophalangeal-interphalangeal (MTP-IP) score, 36-Item Short-Form Health Survey (SF-36) physical component score (PCS) and mental component score (MCS), preoperative hallux valgus angle (HVA) and intermetatarsal angle (IMA), and concomitant procedures. Outcomes were compared at 6 and 24 months postoperatively. Early postoperative VAS scores were also compared.Results:Both groups demonstrated significant improvements in VAS score, AOFAS score, and SF-36 PCS and MCS at 6 and 24 months postoperatively. For the MICA group, HVA improved from 23.5 to 7.7 degrees, and IMA improved from 13.5 to 7.5 degrees. For the scarf-Akin osteotomy group, HVA improved from 23.7 to 9.3 degrees, and IMA improved from 13.6 to 7.8 degrees. The first 24-hour postoperative VAS score was significantly lower in the MICA group compared with the scarf-Akin group (2.0 ± 2.0 vs 3.4 ± 2.6, P = .029). However, there was no significant difference in clinical or radiological outcomes between the groups at 6 and 24 months.Conclusion:The MICA procedure with the new-generation MICA screw is an attractive option for the correction of hallux valgus, yielding similar midterm radiological and clinical outcomes compared with the well-established scarf-Akin osteotomy. The first 24-hour postoperative VAS score in the MICA group was also statistically lower, although its clinical significance remains to be determined.Level of Evidence:Level III, retrospective comparative study.
      Citation: Foot & Ankle International
      PubDate: 2021-10-05T03:18:42Z
      DOI: 10.1177/10711007211049193
       
  • Preoperative Gait Analysis of Peroneal Tendon Tears

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      Authors: Noah Chinitz, Daniel D. Bohl, Manoj Reddy, Shay Tenenbaum, Scott Coleman, James W. Brodsky
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:Little is known regarding the impact of peroneal tendon tears on function. This study quantifies gait changes associated with operatively-confirmed peroneal tendon tears.Methods:Sixty-five patients with unilateral peroneal tendon tears were prospectively evaluated using preoperative 3D multisegment gait analysis of both limbs. Data were analyzed according to pattern/severity of tears, as confirmed surgically: peroneus brevis tears, reparable (PBR); peroneus brevis tears, irreparable (PBI); peroneus longus tears, irreparable (PLI); and concomitant irreparable tears of both tendons (PBI+PLI). The following parameters were analyzed: ankle sagittal motion, coronal motion, axial rotation, foot progression angle, sagittal power, sagittal moment.Results:Twelve patients (18.5%) had the PBR pattern, 37 (56.9%) PBI, 10 (15.4%) PLI, and 6 (9.2%) PBI+PLI. Compared with the contralateral, nonpathologic extremities, limbs with peroneal tears had diminished ankle sagittal motion (mean 23.14 vs 24.30 degrees, P = .012), ankle/hindfoot axial rotation (6.26 vs 7.23 degrees, P = .001), sagittal moment (1.16 vs 1.29 Nm/kg, P < .001), and sagittal power (1.24 vs 1.47 W/kg, P < .001). The most severe tear patterns had the greatest derangements in multiple parameters of gait (PBI+PLI> PBI or PLI> PBR). For example, all groups except PBR had loss of ankle sagittal moment and/or power in the affected limb, and the greatest losses in moment and power were in the PBI+PLI group (1.22 vs 0.91 Nm/kg, P = .003 for moment; 0.73 vs 1.31 W/kg, P < .001 for power). The PBI+PLI group had a>10-degree varus shift in coronal motion on the affected side (P = .002).Conclusion:This is the first study to demonstrate diminished biomechanical function in patients with peroneal tendon tears. In vivo 3-dimensional gait analysis found significant changes in hindfoot motion, ankle motion, and ankle power. Impairments were related to the pattern and severity of the tears, and demonstrated a strong association of peroneal tendon tears with diminished ankle plantarflexion strength.Level of Evidence:Level III, retrospective cohort study.
      Citation: Foot & Ankle International
      PubDate: 2021-10-01T12:30:03Z
      DOI: 10.1177/10711007211036876
       
  • Ultimate Load Measuring System for Fixation of Soft Tissue to Bone

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      Authors: Tatsuya Fujii, Makoto Tateura, Masato Ogawa, Satoru Ozeki
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:The initial ultimate load for graft fixation is one of the essential factors in the reconstruction of lateral ankle ligaments. Several anchoring devices have been developed to fix the substitute ligament into the bone. A fair comparison of these fixation methods warrant a reproducible examination system. The purpose of this study was to make an experimental animal model and to compare the initial ultimate loads of 3 graft fixation methods, including the use of EndoButton (EB), interference screw (IFS), and a novel socket anchoring (SA) technique.Methods:Porcine calcaneus bones and 5-mm-wide split bovine Achilles tendons were used as fixation bases and graft materials, respectively. Both ends were firmly sutured side-by-side, using the circumferential ligation technique as a double-strand substitute that was 45 mm in length. Porcine calcanei with similar characteristics to adult human calcanei were mounted on a tensile testing machine, and substitutes were fixed into bones using the 3 fixation methods. A polyester tape was passed through the tendon loop and connected to a crosshead jig of the testing machine. The initial ultimate loads were measured in 15 specimens for each fixation method to simulate a lateral ankle ligament (LAL) injury.Results:The ultimate loads (ULs) were 223.6 ± 52.7 N for EB, 229.7 ± 39.7 N for SA, and 208.8 ± 65.3 N for IFS. No statistically significant difference was observed among the 3 groups (P = .571). All failures occurred at the bone–ligament substitute interface.Conclusion:The initial ULs in all 3 fixation methods were sufficient for clinical usage. These values were larger than the UL of the anterior talofibular ligament; however, these were smaller than the UL of the calcaneofibular ligament.Clinical Relevance:In an experimental animal model, ULs for SA, EB, and IFS techniques showed no significant difference. All failures were observed in the fixation site of the calcaneus and were overwhelmingly related to suture fixation failure.
      Citation: Foot & Ankle International
      PubDate: 2021-09-30T12:47:31Z
      DOI: 10.1177/10711007211040504
       
  • Slowed-Down Rehabilitation Following Percutaneous Repair of Achilles
           Tendon Rupture

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      Authors: Nicola Maffulli, Nikolaos Gougoulias, Gayle D. Maffulli, Francesco Oliva, Filippo Migliorini
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:Following percutaneous repair of acute Achilles tendon (AT) ruptures, early postoperative weightbearing is advocated; however, it is debatable how aggressive rehabilitation should be. We compared the clinical and functional outcomes in 2 groups of patients who followed either our “traditional” or a “slowed down” rehabilitation after percutaneous surgical repair.Methods:Sixty patients were prospectively recruited to a slowed down (29 patients) or a traditional (31 patients) rehabilitation program. Both groups were allowed immediate weightbearing postoperatively; a removable brace with 5 heel wedges was applied at 2 weeks. In the slowed-down group, 1 wedge was removed after 4 weeks. Gradual removal of the boot took place after 4 wedges were kept for 4 weeks. In the traditional group, 1 wedge was removed every 2 weeks, with removal of the boot after 2 wedges had been kept for 2 weeks. The AT Resting Angle (ATRA) evaluated tendon elongation. Patient reported functional outcomes were assessed using the AT Rupture Score (ATRS). Calf circumference difference and the isometric plantarflexion strength of the gastro-soleus complex were evaluated.Results:At the 12-month follow-up, both ATRA and ATRS were more favorable in the slowed-down group. The isometric strength and the calf circumference were more similar to the contralateral leg in the slowed-down group than in the traditional one.Conclusion:Following percutaneous repair of acute Achilles tendon patients undergoing slowed down rehabilitation performed better than the traditional one. These conclusions must be considered within the limitations of the present study.Level of Evidence:Level II, prospective comparative study.
      Citation: Foot & Ankle International
      PubDate: 2021-09-28T11:10:53Z
      DOI: 10.1177/10711007211038594
       
  • Operative Fixation of Lateral Malleolus Fractures With Locking Plates vs
           Nonlocking Plates: A Systematic Review and Meta-analysis

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      Authors: Nesar Ahmad Hasami, Diederik Pieter Johan Smeeing, Albert Frederik Pull ter Gunne, Michael John Richard Edwards, Stijn Diederik Nelen
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:The exact benefit of locking plates over nonlocking plates in patients with lateral malleolus fractures remains unclear. The primary aim of this study was to compare the functional outcome of locking plates vs nonlocking plates in patients with a lateral malleolus fracture. The secondary aims were to compare the number of complications and hardware removals and to compare whether results differed for older patients and for patients treated with anatomical locking plates.Methods:The PubMed/MEDLINE, Embase, Cochrane, and CINAHL databases were searched for studies comparing locking plates with nonlocking plates in patients with fixated lateral malleolus fractures. All included studies were assessed on their methodologic quality using the MINORS. Subgroup analyses were performed on older patients and patients treated with anatomical locking plates.Results:A total of 11 studies were included. The meta-analysis showed that functional outcome did not differ between patients treated with locking plates and nonlocking plates (MD 2.38, 95% CI −2.71 to 7.46). No difference in both complication rate (OR 1.10, 95% CI 0.74-1.63) and the amount of hardware removals (OR 0.77, 95% CI 0.52-1.14) was found. Even after analyzing older patients and patients treated with anatomical locking plates, no benefit was shown.Conclusion:This meta-analysis demonstrates no clear benefit in selecting locking plates over nonlocking plates in the treatment of lateral malleolus fractures.Clinical Relevance:Locking plates are increasingly being used in the treatment of lateral malleolus fractures. Biomechanical studies have shown an increased stability with use of locking vs nonlocking plates. This clinical review does not support a benefit of use of locking plates for these fractures.
      Citation: Foot & Ankle International
      PubDate: 2021-09-28T11:10:34Z
      DOI: 10.1177/10711007211040508
       
  • Association Between Middle Facet Subluxation and Foot and Ankle Offset in
           Progressive Collapsing Foot Deformity

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      Authors: Nacime Salomão Barbachan Mansur, Matthieu Lalevee, Connor Maly, Kevin Dibbern, Hee Young Lee, Alexandre Leme Godoy-Santos, François Lintz, Cesar de Cesar Netto
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:Subtalar middle facet (MF) subluxation was recognized as a reliable marker for progressive collapsing foot deformity (PCFD) diagnosis. Foot and Ankle Offset (FAO) is an established measurement, predictive of malalignment severity. The objective of this study was to assess the potential association between MF subluxation and FAO in PCFD patients.Methods:56 individuals with flexible PCFD (74 feet) were assessed. Two blinded foot and ankle surgeons calculated MF uncoverage, MF incongruence, and FAO. Agreement was quantified using intraclass correlation coefficient (ICC). A multivariate regression analysis and partition prediction models were applied to assess relationship between values.Results:All ICCs were>0.80. MF subluxation and FAO were found to be correlated (rs = 0.56; P < .0001). Changes in the MF subluxation were noticeably explained by FAO and BMI (R2 = 0.33). MF incongruence was not correlated with the assessed variables (P = .10). In this cohort, an MF subluxation of 27.5% was a threshold for increased FAO (FAO of 3.4%±2.4% when below; FAO of 8.0% ±3.5% when above).Conclusion:We found a correlation between MF subluxation and FAO. An MF subluxation of 27.5% was found to be a threshold for higher FAO, which corresponded to a greater malalignment. These data may help surgeons optimize treatment decisions in PCFD patients.Level of Evidence:Level III, retrospective comparative study.
      Citation: Foot & Ankle International
      PubDate: 2021-09-28T11:10:14Z
      DOI: 10.1177/10711007211040820
       
  • Outcomes and Complications of Open vs Posterior Arthroscopic Subtalar
           Arthrodesis: A Prospective Randomized Controlled Multicenter Study

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      Authors: Chamnanni Rungprai, Aekachai Jaroenarpornwatana, Nusorn Chaiprom, Phinit Phisitkul, Yantarat Sripanich
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:Open subtalar arthrodesis is the standard treatment for subtalar arthritis. Posterior arthroscopic subtalar arthrodesis (PASTA) has recently gained increasing popularity due to a shorter recovery time and better cosmesis. However, studies comparing outcomes and complications between these 2 techniques are limited.Methods:In total, 56 patients with subtalar joint arthritis were prospectively randomized to 2 parallel groups to receive either PASTA (n = 28 patients) or open subtalar arthrodesis (n = 28 patients). The minimum follow-up period was 12 months. Primary outcome was union rate confirmed on postoperative computed tomography (CT) scan. Secondary outcomes were union time; visual analog scale (VAS), Short Form–36 (SF-36), and Foot and Ankle Ability Measure (FAAM) scores; tourniquet time; and complications.Results:Union time (9.4 vs 12.8 weeks) and recovery time (time to return to activities of daily living [8.4 vs 10.8 weeks], work [10.6 vs 12.9 weeks], and sports [24.9 vs 32.7 weeks]) were significantly shorter with PASTA than with the open technique (P < .05 all). Both techniques led to significant improvements in all functional outcomes (FAAM, SF-36, and VAS scores; P < .01 all); however, there was no significant difference between the techniques in these outcomes (P> .05 all). Other outcomes, including tourniquet time (55.8 vs 67.2 min), union rate (96.3% vs 100%), and complication rate, were not significantly different between the techniques.Conclusion:Both open and PASTA techniques led to significant improvements in pain and function in patients with isolated subtalar joint arthritis. Although short-term functional outcomes and complication rates were not significantly different between the techniques, the PASTA technique was better at shortening the union and recovery times.Level of Evidence:Level I, prospective multicenter randomized controlled trial.
      Citation: Foot & Ankle International
      PubDate: 2021-09-28T11:07:17Z
      DOI: 10.1177/10711007211047239
       
  • One-Stage Lengthening and Minimally Invasive Distal Metatarsal Metaphyseal
           Osteotomy (DMMO) for Brachymetatarsia

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      Authors: Felipe Chaparro, Raul Espinoza, Manuel J. Pellegrini, Giovanni Carcuro, Cristian Ortiz
      Abstract: Foot & Ankle International, Ahead of Print.
      Level of Evidence: Level V.
      Citation: Foot & Ankle International
      PubDate: 2021-09-24T12:17:56Z
      DOI: 10.1177/10711007211039526
       
  • Endoscopic Flexor Hallucis Longus Transfer for the Management of Acute
           Achilles Tendon Ruptures in Professional Soccer Players

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      Authors: Nasef Mohamed N. Abdelatif, Jorge Pablo Batista
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:Acute Achilles tendon ruptures (AATRs) that occur in athletes can be a career-ending injury. The aim of this study was to describe return to play and clinical outcomes of isolated endoscopic flexor hallucis longus (FHL) transfer in active soccer players with AATR.Methods:Twenty-seven active male soccer players who underwent endoscopically assisted FHL tendon transfer for acute Achilles tendon ruptures were included in this study. Follow up was 46.2 (±10.9) months after surgery. Return to play criteria and clinical outcome measures were evaluated.Results:All players returned to playing professional competitive soccer games. Return to active team training was at a mean of 5.8 (±1.1) months postoperatively. However, return to active competitive match play occurred at a mean of 8.3 (±1.4) months. Twenty-two players (82%) were able to return to their preinjury levels and performances and resumed their professional careers at the same soccer club as their preinjury state. One player (3.7%) shifted his career to professional indoor soccer. At 26 months postoperatively, the mean Tegner activity scale score was 9.7 (±0.4), the mean Achilles tendon total rupture score was 99 (±2), and the mean American Orthopaedic Foot & Ankle Society ankle-hindfoot score was 99 (±3). No patients reported any great toe complaints or symptomatic deficits of flexion strength.Conclusion:The current study demonstrated satisfactory and comparable return to play criteria and clinical results with minimal complications when using an advanced endoscopically assisted technique involving FHL tendon transfer to treat acute Achilles tendon ruptures in this specific subset of patient cohort.Level of Evidence:Level II, prospective cohort case series study.
      Citation: Foot & Ankle International
      PubDate: 2021-09-24T12:11:57Z
      DOI: 10.1177/10711007211036439
       
  • Short-Term Complications and Outcomes of the Cadence Total Ankle
           Arthroplasty

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      Authors: Brianna Fram, Daniel O. Corr, Ryan G. Rogero, David I. Pedowitz, Justin Tsai
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:Total ankle arthroplasty (TAA) is an increasingly popular option for the operative treatment of ankle arthritis. The Cadence TAA entered clinical use in 2016 and was designed to address common failure modes of prior systems. We report early complications and radiographic and clinical outcomes of this total ankle system at a minimum of 2 years of follow-up.Methods:We performed a retrospective review of a consecutive cohort of patients undergoing primary Cadence TAA by a single surgeon from 2016 to 2017. Complications and reoperations were documented using the American Orthopaedic Foot & Ankle Society (AOFAS) TAA reoperation coding system. Patients completed the Foot and Ankle Ability Measure (FAAM) Activities of Daily Living (ADL) and Sport subscales, SF-12 Mental (MCS) and Physical (PCS) Component Summaries, and visual analog scale (VAS) pain rating (0-100). Radiographic evaluation was performed to assess postoperative range of motion (ROM) of the sole of the foot relative to the long axis of the tibia, alignment, and implant complications.Results:Fifty-eight patients with a mean age of 63.3 years and mean body mass index of 31.9 kg/m2 were included. Twelve of 58 patients (20.7%) underwent an additional procedure(s) within 2 years, including 3 (5.2%) who required removal of one or both components, 2 for infection and 1 for osteolysis. Forty-three patients were followed for a minimum of 2 years with radiographic imaging; 1 patient’s (2.3%) radiographs had signs of peri-implant osteolysis, with no cases demonstrating loosening or subsidence. FAAM-ADL, FAAM-Sport, SF-12 PCS, and VAS pain scores all improved at a mean of 27.4 months postoperatively, with mean score changes (± SD) of 16.3 (± 22.0), 25.3 (± 24.5), 6.0 (± 11.1), and −32.3 (± 39.8), respectively. Radiographic analysis revealed that average coronal alignment improved from 6.9 degrees from neutral preoperatively to 2.3 degrees postoperatively. The average ROM of the foot relative to the tibia was 36.5 degrees total arc of motion based on lateral radiographs.Conclusion:Early experience with this 2-component total ankle replacement was associated with a high component retention rate, improved coronal plane alignment, good postoperative ROM, radiographically stable implants, and improved patient function.Level of Evidence:Level IV, case series.
      Citation: Foot & Ankle International
      PubDate: 2021-09-22T11:14:20Z
      DOI: 10.1177/10711007211043853
       
  • Biomechanical Effects of Graft Shape for the Evans Lateral Column
           Lengthening Procedure: A Patient-Specific Finite Element Investigation

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      Authors: Jiaju Wu, Hua Liu, Can Xu
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:The Evans calcaneal lengthening osteotomy procedure is widely used for correcting progressive collapsing foot deformity. However, it can result in overcorrection and degenerations of the calcaneocuboid joint. Different shapes of graft have been used in the Evans calcaneal osteotomy, but potential differences in their biomechanical effects is still unclear. The present study was designed to explore the biomechanical effects of graft shape and improve the Evans procedure to avoid or minimize detrimental effects.Methods:Twelve patient-specific finite element models were established and validated. A triangular or rectangular wedge of varying size was inserted at the lateral edge of calcaneus, and the degree of correction was quantified. The stress in spring ligaments and plantar fascia and the contact characteristics of the talonavicular and calcaneocuboid joints were calculated and compared accordingly.Results:The rectangular graft provided a much higher degree of correction than triangular grafts did. However, the contact characteristics of the calcaneocuboid joint and talonavicular joint were abnormal, with clear sensitivity to increased graft size, and the modeled strain of the spring ligament increased.Conclusion:The finite element analysis predicts that the rectangular grafts provide a higher degree of correction, but risks overcorrection compared with triangular grafts. The triangular graft may have a lower degree of disturbance to the biomechanical behaviors of the midtarsal joint.Clinical Relevance:The model shows that both the shape and size of an Evans osteotomy bone wedge can have effects on the contiguous joints and ligamentous structures. Those effects should be considered when selecting a bone wedge for an Evans calcaneal osteotomy.Level of Evidence:Level III, case-control study.
      Citation: Foot & Ankle International
      PubDate: 2021-09-22T11:12:17Z
      DOI: 10.1177/10711007211043822
       
  • Arthroscopic Subtalar Joint Arthrodesis: Topical Review

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      Authors: Hesham Oshba, Raghda Hasan AboBakr Shaaban, Islam Abdelrahman, Nikolaos Gougoulias
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:Advances in foot and ankle arthroscopy over the last 2 decades have allowed for subtalar joint arthrodesis to be performed arthroscopically. The potential advantages of the arthroscopic technique include higher fusion rates, lower complications, reduced perioperative morbidity, and accelerated rehabilitation. Arthroscopic arthrodesis may, however, not be appropriate in the setting of complex deformity correction or the need for other open procedures.Methods:Surgical techniques of arthroscopic subtalar joint arthrodesis are described. Outcomes and complications associated with these procedures are presented, based on a comprehensive literature review. Thirteen Level IV studies of moderate quality were included.Results and Conclusion:Excellent arthrodesis union rates were achieved (average 96%, range 86%-100%), at a weighted average union time of 8.8 weeks (95% confidence interval 7.9-9.7). The overall complication rate was 21% (87/415 feet; range 10%-36.4%). Metal irritation was the most common complication (11.2%), followed by nerve injury (4.2%) and infection (0.9%). Similar fusion rates have been reported when comparing arthroscopic and open arthrodesis. Complication rates are also similar, excerpt for infection, which may be lower with arthroscopy. Three different approaches were used to access the subtalar joint with similar union and complication rates. There was no evidence that the use of bone graft or more than 1 screw improved outcomes. The superiority of arthroscopic subtalar fusion over open techniques cannot be demonstrated by the available studies.Level of Evidence:Level IV, case series.
      Citation: Foot & Ankle International
      PubDate: 2021-09-22T11:10:23Z
      DOI: 10.1177/10711007211035397
       
  • Repositional Subtalar Arthrodesis Combined With Supramalleolar Osteotomy
           for Late-Stage Varus Ankle Arthritis With Hindfoot Valgus

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      Authors: Chul Hyun Park, Jaeyoung Kim, Ji Beom Kim, Woo-Chun Lee
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:Late-stage varus ankle arthritis is thought to be associated with varus of the tibial plafond and hindfoot. However, some late-stage varus arthritis show hindfoot valgus, which can be explained by subtalar subluxation with opposite directional motion between the talus and calcaneus. We hypothesized that late-stage varus ankle arthritis with hindfoot valgus could improve with repositional subtalar arthrodesis and supramalleolar osteotomy (SMO). The purpose of this study was to investigate the clinical and radiographic results of the repositional subtalar arthrodesis combined with SMO for late-stage varus ankle arthritis with hindfoot valgus.Methods:This study includes 16 consecutive patients (16 ankles) with late-stage varus ankle arthritis of Takakura stage 3-b and hindfoot valgus who were treated using repositional subtalar arthrodesis combined with SMO and followed for a minimum of 2 years. Clinical results were assessed with the visual analog scale (VAS) and the Foot Function Index (FFI). Radiographic results were assessed with standard parameters measured on weightbearing foot and ankle radiographs. Clinical and radiographic results were evaluated preoperatively and at the last follow-up.Results:VAS and FFI significantly improved after surgery. Mean talar tilt angle improved from 12.8 ± 2.8 degrees to 3.9 ± 3.1 degrees (P < .001). Talus center migration and Meary angle significantly improved after surgery. Medial distal tibial angle, lateral talocalcaneal angle, hindfoot moment arm, and talonavicular coverage angle significantly changed after surgery. Radiographic stage improved in 15 ankles (93.8%) after surgery.Conclusion:In this series with minimum 2-year follow-up, we found that late-stage (Takakura stage 3-b) varus ankle arthritis with hindfoot valgus clinically and radiographically improved with repositional subtalar arthrodesis combined with SMO.Level of Evidence:Level IV, prognostic.
      Citation: Foot & Ankle International
      PubDate: 2021-09-17T05:19:41Z
      DOI: 10.1177/10711007211036699
       
  • Fully Intra-articular Lasso-Loop Stitch Technique for Arthroscopic
           Anterior Talofibular Ligament Repair

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      Authors: Jiajun Qin, Qiang Fu, Qing Zhou, Helin Wu, Xiaosong Zhi, Feng Xu, Xianhua Cai, Shijun Wei
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:Arthroscopic techniques have gradually become popular for anterior talofibular ligament (ATFL) repair. However, the reliability of the repair and the risk of nerve injuries are of concern. The aim of this study was to evaluate the fully intra-articular lasso-loop stitch technique for arthroscopic ATFL repair.Methods:From October 2018 to December 2019, 43 cases with chronic lateral ankle instability were treated with this fully intra-articular lasso-loop stitch technique using the Arthro-Pierce instrument. The Karlsson-Peterson score, Cumberland Ankle Instability Tool (CAIT) score, visual analog scale (VAS) score, anterior drawer and talar tilt stress fluoroscopy were evaluated at the preoperative and final follow-up appointments, respectively. All surgical complications were also recorded.Results:A total of 39 cases were followed up for a mean of 28.23 ± 3.64 months (range, 23-34 months). At the final follow-up, the averages of the Karlsson-Peterson, CAIT and VAS scores were 90.26 ± 6.58, 88.56 ± 7.21 and 0.79 ± 1.06, respectively. During surgery, 2 cases were modified with augmentation of the inferior extensor retinaculum. No nerve injuries were encountered. Only 1 female complained about mild knot irritation. A 25-year-old solider required revision surgery due to an accidental injury.Conclusion:We found the fully intra-articular lasso-loop stitch technique for ATFL repair using the Arthro-Pierce instrument to be reliable and safe with a sufficient and good-quality ligament remnant.Level of Evidence:Level IV, retrospective case series.
      Citation: Foot & Ankle International
      PubDate: 2021-09-11T02:31:04Z
      DOI: 10.1177/10711007211044442
       
  • Articular Cartilage of the Syndesmosis: Avoiding Iatrogenic Cartilage
           Injury During Syndesmotic Fixation

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      Authors: Jeffrey A. Gilbertson, Matthew C. Sweet, Joseph K. Weistroffer, James R. Jastifer
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:The optimal surgical management of syndesmosis injuries consists of internal fixation between the distal fibula and tibia. Much of the available data on this joint details the anatomy of the syndesmotic ligaments. Little is published evaluating the distribution of articular cartilage of the syndesmosis, which is of importance to minimize the risk of iatrogenic damage during surgical treatment. The purpose of this study is to describe the articular cartilage of the syndesmosis.Methods:Twenty cadaveric ankles were dissected to identify the cartilage of the syndesmosis. Digital images of the articular cartilage were taken and measured using calibrated digital imaging software.Results:On the tibial side, distinct articular cartilage extending above the plafond was identified in 19/20 (95%) specimens. The tibial cartilage extended a mean of 6 ± 3 (range, 2-13) mm above the plafond. On the fibular side, 6/20 (30%) specimens demonstrated cartilage proximal to the talar facet, which extended a mean of 24 ± 4 (range, 20-31) mm above the tip of the fibula. The superior extent of the syndesmotic recess was a mean of 10 ± 3 (range, 5-17) mm in height. In all specimens, the syndesmosis cartilage did not extend more than 13 mm proximal to the tibial plafond and the syndesmotic recess did not extend more than 17 mm proximal to the tibial plafond.Conclusion:Syndesmosis fixation placed more than 13 mm proximal to the tibial plafond would have safely avoided the articular cartilage in all specimens and the synovial-lined syndesmotic recess in most.Clinical Relevance:This study details the articular anatomy of the distal tibiofibular joint and provides measurements that can guide implant placement during syndesmotic fixation to minimize the risk of iatrogenic cartilage damage.
      Citation: Foot & Ankle International
      PubDate: 2021-09-08T05:56:18Z
      DOI: 10.1177/10711007211041325
       
  • Anatomical Study of Sinus Tarsi–Based Lateral Lengthening Calcaneal
           Osteotomy

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      Authors: Matthias Aurich, Mark Lenz, Gunther O. Hofmann, Wiebke Schubert, Matthias Knobe, Klaus Edgar Roth, Paul Simons, Kajetan Klos
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:Lateral lengthening calcaneal osteotomy (LL-CO) is commonly performed as a treatment for an abducted midfoot in pes planovalgus deformity. The purpose of this study is to investigate potential damage to medial structures with a sinus tarsi LL-CO.Methods:Sixteen cadaver feet were used. Eight feet had an extended lateral approach, and 8 had a limited lateral (sinus tarsi) approach. All underwent a sinus tarsi LL-CO. Specimens were then dissected to identify inadvertent injury to medial structures.Results:Sinus tarsi LL-CO was associated with damage to the sustentaculum tali and medial articular facets in 56% and 62.5% of specimens, respectively. No anterior or posterior facet injuries were found, although 56% of specimens had a confluent medial and anterior facet.Conclusion:Damage to the medial articular facet and sustentaculum is possible with a flat cut sinus tarsi LL-CO due to the curved nature of the relevant sinus tarsi and canal anatomy.Clinical Relevance:Sinus tarsi LL-CO needs to be performed with caution since damage to the subtalar joint is possible.Level of Evidence:Level II, prospective cohort study.
      Citation: Foot & Ankle International
      PubDate: 2021-09-07T09:50:59Z
      DOI: 10.1177/10711007211041345
       
  • Oblique Opening Wedge Osteotomy for Distal Tibial Varus Secondary to
           Physeal Arrest

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      Authors: Stewart G. Morrison, Andrew G. Georgiadis, Mark T. Dahl
      Abstract: Foot & Ankle International, Ahead of Print.

      Citation: Foot & Ankle International
      PubDate: 2021-09-02T06:14:56Z
      DOI: 10.1177/10711007211041324
       
  • Repeatability of Weightbearing Computed Tomography Measurement of First
           Metatarsal Alignment and Rotation

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      Authors: Ali-Asgar Najefi, Mohammad Khalid Alsafi, Karan Malhotra, Shelain Patel, Nicholas Cullen, Matthew Welck
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:Weightbearing computed tomography (WBCT) can be used to assess alignment and rotation of the first metatarsal. It is unknown whether these measures remain consistent on sequential WBCTs in the same patient when a patient’s standing position may be different. The aim of this study was to establish the repeatability (test-retest) of measurements of first metatarsal alignment and rotation in patients without forefoot pathology on WBCT.Methods:We retrospectively identified 42 feet in 26 patients with sequential WBCT studies less than 12 months apart. Patients with surgery between scans, previous forefoot surgery or hallux rigidus were excluded. Hallux valgus angle (HVA) and intermetatarsal angle (IMA) were measured using digitally reconstructed radiographs. Two methods of calculating metatarsal rotation (metatarsal pronation angle [MPA] and alpha angle) were measured on standardized coronal CT slices. Interobserver agreement and test-retest repeatability were assessed using intraclass correlation coefficients (ICCs). Standard error of measurement (SEM) and minimally detectable change (MDC95) were calculated.Results:Interobserver agreement was excellent for HVA and IMA (ICC 0.96 and 0.90, respectively) and was good for MPA and alpha angle (ICC 0.81 and 0.80, respectively). There was excellent test-retest repeatability for HVA (ICC=0.90) and good test-retest repeatability for IMA (ICC=0.77). There was excellent test-retest repeatability for MPA (ICC=0.91) and good test-retest repeatability for alpha angle (ICC=0.87). The MDC95 was 4.6 degrees for MPA and 6.1 degrees for alpha angle. Five percent of patients had a difference outside of the MDC95 for the alpha angle, compared with 2% for the MPA.Conclusion:Measurements of first metatarsal alignment and rotation are reliable between assessors and repeatable between sequential WBCTs in patients without forefoot pathology. Subtle differences in patient positioning during image acquisition do not significantly affect measurements, supporting the validity of this method of assessment in longitudinal patient care.Level of Evidence:Level IV, retrospective case series.
      Citation: Foot & Ankle International
      PubDate: 2021-08-21T04:51:30Z
      DOI: 10.1177/10711007211035387
       
  • Interdigital vs Transarticular Lateral Release With Scarf Osteotomy

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      Authors: Florian Hartenbach, Brigitta Höger, Karl-Heinz Kristen, Hans-Jörg Trnka
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:We compare the clinical and radiographic outcomes of the interdigital approach vs the medial transarticular approach for lateral release combined with scarf osteotomy.Methods:Seventy-seven feet with moderate to severe hallux valgus underwent scarf osteotomy and lateral soft tissue release, using an interdigital approach (n = 36) vs medial transarticular approach (n = 41). The clinical measurements (range of motion, American Orthopaedic Foot and Ankle Society [AOFAS] score) and radiographic data were evaluated preoperatively and at final follow-up (93-124 months postoperatively). Additionally, the numeric pain rating scale and Foot and Ankle Outcome score [FAOS] were assessed postoperatively.Results:The AOFAS score improved from 60 (q1 = 54, q3 = 70) to 93 (q1 = 85, q3 = 98) in the transarticular group, and from 59 (q1 = 50, q3 = 64) to 95 (q1 = 85, q3 = 100) in the interdigital group. The hallux valgus angle improved from 35.7±6.5 degrees to 15.5±7.6 degrees in the transarticular group, and from 36.0±6.8 degrees to 12.9±13.0 degrees in the interdigital group. The intermetatarsal angle improved from 16.5±2.5 degrees to 6.5±2.7 degrees within the transarticular group and from 17.2±2.5 degrees to 7.3±4.3 degrees in the interdigital group. None of the clinical or radiographic parameters showed any significant differences between the treatment groups.Conclusion:Comparison of outcomes between the interdigital approach and the transarticular approach for lateral soft-tissue release with scarf osteotomy are equally successful. The transarticular approach can thus be considered safe and effective, with the additional benefits of just one scar as opposed to 2.Level of Evidence:Level III, therapeutic.
      Citation: Foot & Ankle International
      PubDate: 2021-08-20T09:34:50Z
      DOI: 10.1177/10711007211035374
       
  • Minimally Invasive Distal Metatarsal Metaphyseal Osteotomy of the Lesser
           Toes: Clinical, Radiologic, and Pedobarographic Outcomes

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      Authors: Elena Neunteufel, Sabine Krenn, Michel Chraim, Pascal Amann, Fabian Greiner, Andreas Kranzl, Peter Bock
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:The minimally invasive distal metatarsal metaphyseal osteotomy (DMMO) is a percutaneous operative technique with the aim to relieve the symptoms of metatarsalgia. To our knowledge, no previous research has analyzed both pre- and postoperative pedobarographic data including the changes in plantar pressure.Methods:Thirty patients (31 feet) were operated on with a DMMO and included in a prospective study. Clinical, radiologic, and pedobarographic outcomes were evaluated in comparison with the preoperative parameters. The American Orthopaedic Foot & Ankle Society (AOFAS) forefoot score, the Foot Function Index (FFI), the Foot and Ankle Outcome Score (FAOS), and a visual analog scale (VAS) for pain were used in order to assess clinical parameters. Radiographs were taken to compare metatarsal lengths. The pedobarographic analysis served to determine plantar peak pressure (PPP) beneath the metatarsophalangeal (MTP) joints.Results:All scores indicated a significant mean pre- to postoperative improvement (AOFAS = 31.9 points, FAOS = 16.3%, FFI = 24.3%, VAS pain = 4.1 points, VAS general limitation = 3.3 points) (P < .05). PPP was substantially reduced in the relevant area (M6 [plantar area beneath the second and third MTP joint] had a mean pre to post PPP = 14.15 N/cm2) and concurrently higher in the lateral and medial MTP joint areas (M5 mean pre to post = +14.37, M7 pre to post = +7.11). Our mean metatarsal shortening was 6.6 mm. However, our findings do not demonstrate a significant correlation between metatarsal length relationships and the prevalence of metatarsalgia.Conclusion:Our results demonstrate a significant improvement in clinical scores and PPP. A statistically significant relation between metatarsal length and the prevalence of metatarsalgia was not found in this prospective case seriesLevel of Evidence:Level IV, case series.
      Citation: Foot & Ankle International
      PubDate: 2021-08-18T05:35:52Z
      DOI: 10.1177/10711007211034849
       
  • Treatment of Navicular Stress Fractures With an Algorithmic Approach

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      Authors: James A. Nunley, Cynthia Green, Joel Morash, Mark E. Easley
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:Navicular stress fractures are becoming increasingly more common. There is no universal consensus on treatment. We provide an algorithm that we feel will be useful in determining treatment.Methods:A retrospective study was performed on all patients having operative treatment of navicular stress fractures during a 10-year period. Acute fractures were treated with open reduction internal fixation. Chronic fractures greater than 3 months were treated with open reduction and internal fixation (ORIF) and iliac crest bone grafting. Chronic fractures with evidence of sclerosis, avascular changes, or those who failed previous surgery were treated with ORIF, iliac crest bone grafting, as well as vascular bone grafting. Patients’ pain scores were recorded and a return-to-sports scale was used. Radiographic union was compared among the 3 groups using computed tomographic (CT) scans or radiographs.Results:Forty-three patients were identified. Fifteen received ORIF alone, 12 were treated with ORIF and bone graft, and 16 had ORIF with vascularized bone grafting. No difference was found among the median age of the 3 groups. In terms of radiographic healing, 3 patients in the ORIF group received radiographs alone. All other patients had follow-up CT scans. ORIF alone group had 80% union, ORIF with bone graft had 75% union, and ORIF with vascularized bone grafting had 100% union. Return to sports did not show any difference among the 3 groups.Conclusion:The algorithm dividing navicular stress fractures into 3 distinct groups with different operative techniques helped us address these difficult cases. Vascularized bone grafting certainly appeared to be beneficial for the more difficult cases.Level of Evidence:Level IV, case series.
      Citation: Foot & Ankle International
      PubDate: 2021-08-18T05:30:22Z
      DOI: 10.1177/10711007211034812
       
  • Evaluation of the Foot Arch in Partial Weightbearing Conditions

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      Authors: Tadashi Kimura, Eric D. Thorhauer, Matthew W. Kindig, Bruce J. Sangeorzan, William R. Ledoux
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:Weightbearing plain radiography or computed tomography (CT) is used for diagnosis or treatment selection in foot disorders. This study compared foot alignment between full weightbearing (50% body weight [BW] per foot) plain radiography and nonweightbearing (0% BW) or partial weightbearing (10% BW per foot) CT scans.Methods:Subjects had both full (50% BW per foot) weightbearing plain radiographs and either a nonweightbearing (0% BW) or a partial weightbearing (20% BW or 10% BW per foot) CT scan. Feet (n = 89) had been previously classified as pes cavus (n = 14/17 [subjects/feet]), neutrally aligned (NA; 20/30), asymptomatic pes planus (APP; 18/24), and symptomatic pes planus (SPP; 15/18). Lateral talometatarsal angle (LTMA) and calcaneal pitch angle were compared between weightbearing radiography and maximum-intensity projection images generated from CT.Results:Significant differences in LTMA were found between nonweightbearing CT scans and full (50% BW per foot) weightbearing plain radiographs: the mean difference was 6.6 degrees in NA, 9.2 degrees in APP, and 11.3 degrees in SPP (P < .0001); no significant difference in LTMA was found for pes cavus. Although the interaction of foot type (P = .084) approached statistical significance, pairwise differences between 10% weightbearing and 50% weightbearing images by foot type were significant but small. The 50% weightbearing condition resulted in calcaneal pitch angles the same or slightly lower or higher than those of the 10% weightbearing and nonweightbearing images. LTMA and calcaneal pitch angle measurements made on full (50% BW per foot) weightbearing plain radiographs and non- (0%) or partial (10% BW per foot) weightbearing angles from CT scans were strongly correlated.Conclusion:Different foot types have similar 2-dimensional sagittal plane morphologies with partial weightbearing (10% BW per foot) CT scans and, to a lesser degree, nonweightbearing (0%) neutral-position CT scans when compared to full weightbearing (50% BW per foot) plain radiographs.Level of Evidence:Level III Retrospective case control study.
      Citation: Foot & Ankle International
      PubDate: 2021-08-18T05:27:44Z
      DOI: 10.1177/10711007211034804
       
  • Radiographic Outcomes of Proximal vs Distal Syndesmotic Low Tibial
           Osteotomy

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      Authors: Jun Young Choi, Jin Ho Cho, Tae Hun Song, Jin Soo Suh
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:We aimed to determine whether the location of tibial osteotomy affects the outcome during low tibial osteotomy (LTO) with fibular osteotomy for varus ankle arthritis by comparing proximal syndesmotic (PS) and distal syndesmotic (DS) tibial osteotomy.Methods:We retrospectively reviewed the radiographic findings of 50 cases (among 47 patients) who underwent LTO with fibular osteotomy for varus ankle arthritis. The enrolled patients were divided into 2 groups according to the location of the tibial osteotomy: the PS group (25 cases, 24 patients) and the DS group (25 cases, 23 patients). Radiographic parameters were compared between the 2 groups.Results:There were no significant differences in tibial anterior and lateral surface angles, tibiomedial malleolar angle, talar center migration, and intermalleolar distance correction between the 2 groups (all P> .05). However, the decreases in talar tilt (TT) and talocrural angle (TCA) were more pronounced in the DS group than in the PS group (both P < .05). Among patients with TT ≥8 degrees, a greater decrease in TT (+1.0 degrees vs –2.8 degrees) and TCA was observed in the DS group, whereas the PS group demonstrated greater increases in TCA and intermalleolar distance (all P < .01).Conclusion:In this series, DS tibial osteotomy combined with fibular osteotomy was a more effective operative option than PS tibial osteotomy to correct both extra- and intra-articular deformity for varus ankle arthritis.Level of evidence:Level III, retrospective comparative study.
      Citation: Foot & Ankle International
      PubDate: 2021-08-13T05:03:49Z
      DOI: 10.1177/10711007211035784
       
  • Talar Dome Access Through Posteromedial Surgical Intervals for Fracture
           Care

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      Authors: Graham J. DeKeyser, Dillon C. O’Neill, Yantarat Sripanich, Amy L. Lenz, Charles L. Saltzman, Justin M. Haller, Alexej Barg
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:Posterior talar body fractures are rare injuries without a consensus surgical approach. This study evaluates the accessible area of the talar dome through 2 posteromedial approach intervals (posteromedial [PM] and modified posteromedial [mPM]) both with and without distraction.Methods:Ten male cadaveric legs (5 matched pairs) were included. A PM approach, between flexor hallucis longus (FHL) and the tibial neurovascular bundle, and an mPM approach, between FHL and Achilles tendon, was performed on each pair. In total, 4 mm of distraction across the tibiotalar joint was applied with the foot held in neutral position. Accessible dome surface area (DSA) was outlined by drilling with a 1.6-mm Kirschner wire with and without distraction. Specimens were explanted and analyzed by micro–computed tomography with 3-dimensional reconstruction. Primary outcomes were total accessible DSA and sagittal plane access at predetermined intervals.Results:The PM approach allowed access to 19.1% of the talar DSA without distraction and 33.1% of the talar dome with distraction (P < .001). The mPM approach provided access to 20.4% and 35.6% of the talar DSA without and with distraction (P < .001). Both approaches demonstrated similar sagittal plane access at all intervals except the lateral border of the talus, where the mPM approach provided greater access both without distraction (20.5% vs 4.38%, P = .002) and with distraction (34.3% vs 17.8%, P = .02).Conclusion:The mPM approach, using an interval between FHL and Achilles tendon, provides similar access to the posterior surface of talar dome and better sagittal plane access to the most lateral portion of the dome. The mPM interval provides the advantage of avoiding direct dissection of the tibial nerve or posterior tibial artery. Using an external fixator for distraction can improve talar dome visualization substantially.Level of Evidence:Level V, Cadaveric Study.
      Citation: Foot & Ankle International
      PubDate: 2021-08-13T05:02:36Z
      DOI: 10.1177/10711007211036720
       
  • Is There a Borderline Value in the Radiological Findings of Patients With
           Calcaneal Malunion That May Help to Select an Appropriate Treatment
           Option'

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      Authors: Nikita Konovalchuk, Evgenii Sorokin, Viktor Fomichev, Dmitrii Chugaev, Alexander Kochish, Ekaterina Pashkova, Kirill Mikhaylov
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:Despite the constant evolution of technological support, operative techniques, and rehabilitation techniques after conservative treatment and operative treatment, a considerable number of patients with calcaneal fractures have constant pain, frequently resulting in loss of occupation. There are numerous options for the operative treatment of painful calcaneal malunion; however, very few publications suggest specific radiological measurements for pre- and postoperative planning—even fewer have statistically analyzed how these radiological measurements affect clinical outcomes.Methods:We performed a retrospective study of 100 patients after operative treatment of calcaneal malunion to determine the correlation between radiological measurements and clinical outcomes. Data were used to create an algorithm that would help to choose between in situ subtalar arthrodesis and complex reconstructive operations. The algorithm was then used to treat 27 prospective patients. The American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score and visual analog scale (VAS) were used for clinical assessment, whereas standard weightbearing anteroposterior (AP), lateral (LAT) ankle x-rays, and long axial hindfoot view were used for radiological assessment.Results:The talar declination angle was positively correlated with clinical outcome. Patients with talar declination angles less than 6.5 degrees showed worse results in AOFAS score than patients with a greater angle did (57.3 ± 15.3 and 81 ± 15.6, respectively).Conclusion:The combination of subtalar arthrodesis with distraction bone block or calcaneal osteotomy in patients with calcaneal malunion and a talar declination angle less than 6.5 degrees showed better results than isolated in situ arthrodesis.Level of EvidenceLevel III, retrospective cohort study, case series.
      Citation: Foot & Ankle International
      PubDate: 2021-08-13T04:59:39Z
      DOI: 10.1177/10711007211027298
       
  • Weightbearing CT Analysis of the Transverse Tarsal Joint During Eversion
           and Inversion

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      Authors: Nicholas Rowe, Cassandra E. Robertson, Stuti Singh, John T. Campbell, Clifford L. Jeng
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:Understanding of the movement and function of the transverse tarsal joint (TTJt) continues to evolve. Most studies have been done in cadavers or under nonphysiologic conditions. Weightbearing computed tomographic (WBCT) scans may provide more accurate information about the position of the TTJt when the hindfoot is in valgus or varus.Methods:Five volunteers underwent bilateral weightbearing CT scans while standing on a platform that positioned both hindfeet in 20 degrees of valgus and 20 degrees of varus. Each bone of the foot was segmented, and the joint surfaces of the talus, calcaneus, cuboid, and navicular were identified. The principal axes for each joint surface were determined and used to calculate the angles and distances between the bones with the foot in valgus or varus.Results:In the coronal plane, the angle between the talus and calcaneus rotated 17.1 degrees as the hindfoot moved from valgus to varus. The distance between the centers of the talus and calcaneus decreased 7.1 mm. The cuboid translated 3.9 mm medially relative to the calcaneus. There was no change in angle or distance between the cuboid and navicular. The navicular rotated 25.4 degrees into varus relative to the talus.Conclusion:The TTJt locking mechanism was previously thought to occur from the talonavicular and calcaneocuboid joint axes moving from parallel to divergent as the hindfoot inverts. The current data show a more complex interaction between the four bones that comprise the TTJt and suggests that the locking mechanism may occur because of tightening of the ligaments and joint capsules.Clinical relevance:This study uses weight bearing CT scans of healthy, asymptomatic volunteers standing on valgus and varus platforms to characterize the normal motion of the transverse tarsal joint of the foot. A better understanding of how the transverse tarsal joint functions may assist clinicians in both the conservative and surgical management of hindfoot pathology.
      Citation: Foot & Ankle International
      PubDate: 2021-08-11T10:58:57Z
      DOI: 10.1177/10711007211034821
       
  • The Effect of the Mobile Subtalar Joint on Calcaneal and Supramalleolar
           Osteotomies

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      Authors: Fabian Krause, Ivan Zderic, Boyko Gueorguiev, Anandakumar Vellasamy, Timo Schmid
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:The mobile subtalar joint (STJ) may compensate for supra- and inframalleolar deformities and counteract the effect of realigning calcaneal or distal tibial osteotomies. The purpose of this study was to evaluate the compensatory effect of the mobile STJ after supramalleolar osteotomy (SMOT) and calcaneus osteotomy (COT) and whether the extent of the compensation correlates with STJ shape and orientation.Methods:In 10 human lower leg cadavers without evidence of deformity or prior trauma 700 Newton load were applied as a simulated standing pose. The center of force (COF) migration, maximum pressure (Pmax), and the area loaded were measured with high-resolution sensors in the ankle before and after 10-mm varus/valgus sliding COT and 10-degree varus / valgus SMOT. A computed tomographic evaluation of subtalar anatomy was conducted to correlate posterior facet curvature, its varus/valgus orientation in the coronal plane, and the effect on COF, Pmax, and area loaded.Results:The COF migration was significant for both varus and valgus SMOTs (varus SMOT: 1.78 mm, P = .0029; valgus SMOT: 1.85 mm, P = .0018) but not for COT (varus COT: 0.45 mm, P = .85; valgus COT: 1.15 mm, P = .11). Pmax and area loaded changed but not significantly. The radius of the posterior STJ surface showed a moderate correlation (varus SMOT: r = 0.61, P = .063; valgus SMOT: r = 0.28, P = .43, varus COT: r = −0.61, P = .063; valgus COT: r = 0.13, P = .38) and the axis a weak inverse correlation (varus SMOT: r = −0.51, P = .013; valgus SMOT: r = 0.58, P = .079; varus COT: r = −0.51, P = .14; valgus COT: r = 0.38, P = .28) with the COF migration after the osteotomies.Conclusion:The compensatory capacity of a mobile STJ is relatively small but appears to limit the effect of COT more than SMOT. The COT is less effective in influencing ankle joint pressure for realignment purposes than SMOT in mobile STJ and clinically more consistent in stiff STJ. Correlations are moderate to weak, whereas the curvature more than orientation of posterior facet inversely correlates with osteotomy’s effects.Level of Evidence:IV (biomechanical cadaver study).
      Citation: Foot & Ankle International
      PubDate: 2021-08-11T10:56:00Z
      DOI: 10.1177/10711007211027295
       
  • High Reliability for Semiautomated 3D Measurements Based on Weightbearing
           CT Scans

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      Authors: Peter Kvarda, Nicola Krähenbühl, Roman Susdorf, Arne Burssens, Roxa Ruiz, Alexej Barg, Beat Hintermann
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:A reliable assessment of the ankle using weightbearing radiography remains challenging. Semiautomated 3-dimensional (3D) measurements derived from weightbearing computed tomography (WBCT) scans may provide a more reliable approach.Methods:Thirty healthy individuals without any foot and ankle disorder were analyzed. We assessed 6 widely used ankle parameters (4 angles and 2 distances) using either semiautomated 3D (based on WBCT scans) or traditional 2-dimensional (2D; based on conventional radiographs) measurements. The reliability and discrepancy between both techniques were compared using intraclass correlation coefficients and the Bland-Altman method.Results:Five of 6 variables showed a lower reliability when derived from 2D measurements. The mean of 3 variables differed between the techniques: the 3D technique assessed that the talonavicular coverage angle was 18.9 degrees higher, the axial talocalcaneal angle was 5.5 degrees higher, and the talocalcaneal overlap was 3.7 mm lower when compared with 2D measurements.Conclusion:Semiautomated 3D measurements derived from WBCT scans provide more reliable information on ankle alignment compared with 2D measurements based on weightbearing radiographs. Future studies may show to what extent these parameters could contribute to current diagnostic algorithms and treatment concepts.Level of Evidence:Not applicable.
      Citation: Foot & Ankle International
      PubDate: 2021-08-06T05:31:38Z
      DOI: 10.1177/10711007211034522
       
  • Health-Related Outcomes 3-15 Years Following Ankle Sprain Injury in Youth
           Sport: What Does the Future Hold'

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      Authors: Oluwatoyosi B. A. Owoeye, Jackie L. Whittaker, Clodagh M. Toomey, Anu M. Räisänen, Jacob L. Jaremko, Lisa C. Carlesso, Sarah L. Manske, Carolyn A. Emery
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:This study examined the association between youth sport-related ankle sprain injury and health-related outcomes, 3-15 years postinjury.Methods:A historical cohort study in which uninjured controls were cluster-matched with injured cases. The primary outcome was self-reported Foot and Ankle Outcome Score (FAOS). Secondary outcomes included measures of adiposity, validated questionnaires for physical activity, athletic identity, fear of pain, and tests of strength, balance, and function.Results:We recruited 86 participants (median age of 23 years; 77% female); 50 with a time-loss ankle sprain, median of 8 years postinjury, and 36 uninjured controls cluster-matched by sex and sport. Based on mixed effects multivariable regression models, previously injured participants demonstrated poorer outcomes than controls on all 5 FAOS subscales regardless of sex and time since injury, with the largest differences observed in symptoms (−20.9, 99% CI: −29.5 to −12.3) and ankle-related quality of life (−25.3, 99% CI: −34.7 to −15.9) subscales. Injured participants also had poorer unipedal dynamic balance (−1.9, 99% CI: 3.5 to −0.2) and greater fear of pain (7.2, 99% CI: 0.9-13.4) compared with controls. No statistically significant differences were found for other secondary outcomes.Conclusion:At 3-15 years following time-loss ankle sprain injury in youth sport, previously injured participants had more pain and symptoms, poorer self-reported function, ankle-related quality of life, reduced sport participation, balance, and greater fear of pain than controls. This underlines the need to promote the primary prevention of ankle sprains and secondary prevention of potential health consequences, including posttraumatic osteoarthritis.Level of Evidence:Level III, historical cohort study.
      Citation: Foot & Ankle International
      PubDate: 2021-08-06T05:30:38Z
      DOI: 10.1177/10711007211033543
       
  • First-Ray Radiographic Changes After Flexible Adult Acquired Flatfoot
           Deformity Correction

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      Authors: Chien-Shun Wang, Yun-Hsuan Tzeng, Tzu-Cheng Yang, Chun-Cheng Lin, Ming-Chau Chang, Chao-Ching Chiang
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:Adult acquired flatfoot deformity (AAFD) and hallux valgus (HV) are common foot and ankle deformities. Few studies have reported the changes in radiographic parameters of HV after reconstructive surgery for AAFD. This study aimed to evaluate the changes in radiographic parameters of HV and analyze the risk factors for increased HV after correction of AAFD.Methods:Adult patients with flexible AAFD who underwent similar bony procedures including medializing calcaneal osteotomy and Cotton osteotomy were included. Radiographic parameters were measured on weightbearing radiographs preoperatively, postoperatively, and at the final follow-up. Patients were divided into hallux valgus angle (HVA) increased and HVA nonincreased groups; logistic regression analysis was performed to identify risk factors affecting increased HV.Results:Forty-six feet of 43 patients were included. After AAFD reconstructive surgery, the tibial sesamoid position improved by 1 grade, but the HVA increased 4 degrees in average. Further, 21 of 46 feet (46%) showed an HVA increase ≥5 degrees immediately after AAFD correction surgery. Preoperative talonavicular coverage angle
      Citation: Foot & Ankle International
      PubDate: 2021-08-05T12:13:57Z
      DOI: 10.1177/10711007211034516
       
  • Association Between Hindfoot Alignment and First Metatarsal Rotation

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      Authors: Neil Bakshi, Jesse Steadman, Matthew Philippi, Christopher Arena, Richard Leake, Charles L. Saltzman, Alexej Barg
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:The association between forefoot and hindfoot position for planus and cavus feet is fundamental to the treatment of these deformities. However, no studies have evaluated the association between hindfoot alignment and first metatarsal (M1) axial rotation. Understanding this possible relationship may help to understand the deformity and improve patient care. The purpose of this study is to determine a correlation between hindfoot alignment and metatarsal rotation as assessed by weightbearing computed tomography (WBCT).Methods:Patients who underwent weightbearing plain radiography (WBPR) and WBCT between 2015 and 2018 were evaluated. Hindfoot alignment was measured with the calcaneal moment arm (CMA). M1 rotation was measured using the Kim and Saltzman angles. Patient subgroups were created according to the severity of valgus/varus hindfoot alignment. Statistical analyses were performed to evaluate for association between variables.Results:Among the 196 patient feet included in the study, the average CMA was 6.0 ± 16.2 mm. The average Kim and Saltzman angles were 7.7 ± 12.9 degrees and 2.8 ± 13.1 degrees, respectively. The average Meary angle was 182.0 ± 11.9 degrees. A moderately strong association was found between the CMA and the Saltzman (r = 0.641, P < .01) and Kim angles (r = 0.615, P < .01). Hindfoot valgus was associated with M1 pronation and hindfoot varus with M1 supination. Additionally, inverse relationships between the Meary angle and the Saltzman (r = −0.600, P < .01) and Kim angles (r = −0.529, P < .01) were identified.Conclusion:In this well-defined cohort, we found substantial correlation between hindfoot alignment and M1 rotation. Hindfoot valgus was associated with M1 pronation, and hindfoot varus was associated with M1 supination. Surgeons correcting cavovarus/planovalgus deformities should be aware of this association and evaluate the need for first-ray derotation.Level of Evidence:Level III, retrospective cohort study.
      Citation: Foot & Ankle International
      PubDate: 2021-08-05T12:09:41Z
      DOI: 10.1177/10711007211033514
       
  • Biomechanical Evaluation of Tarsometatarsal Fusion Comparing Crossing Lag
           Screws and Lag Screw With Locking Plate

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      Authors: Sarah Ettinger, Lisa-Christin Hemmersbach, Michael Schwarze, Christina Stukenborg-Colsman, Daiwei Yao, Christian Plaass, Leif Claassen
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:Tarsometatarsal (TMT) arthrodesis is a common operative procedure for end-stage arthritis of the TMT joints. To date, there is no consensus on the best fixation technique for TMT arthrodesis and which joints should be included.Methods:Thirty fresh-frozen feet were divided into one group (15 feet) in which TMT joints I-III were fused with a lag screw and locking plate and a second group (15 feet) in which TMT joints I-III were fused with 2 crossing lag screws. The arthrodesis was performed stepwise with evaluation of mobility between the metatarsal and cuneiform bones after every application or removal of a lag screw or locking plate.Results:Isolated lag-screw arthrodesis of the TMT I-III joints led to significantly increased stability in every joint (P < .05). Additional application of a locking plate caused further stability in every TMT joint (P < .05). An additional crossed lag screw did not significantly increase rigidity of the TMT II and III joints (P> .05). An IM screw did not influence the stability of the fused TMT joints. For TMT III arthrodesis, lag-screw and locking plate constructs were superior to crossed lag-screw fixation (P < .05). TMT I fusion does not support stability after TMT II and III arthrodesis.Conclusion:Each fixation technique provided sufficient stabilization of the TMT joints. Use of a lag screw plus locking plate might be superior to crossed screw fixation. An additional TMT I and/or III arthrodesis did not increase stability of an isolated TMT II arthrodesis.Clinical Relevance:We report the first biomechanical evaluation of TMT I-III arthrodesis. Our results may help surgeons to choose among osteosynthesis techniques and which joints to include in performing arthrodesis of TMT I-III joints.
      Citation: Foot & Ankle International
      PubDate: 2021-08-05T01:04:22Z
      DOI: 10.1177/10711007211033541
       
  • Low Donor Site Morbidity Associated With Tricortical Calcaneal Bone Graft

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      Authors: Gabriel Ferraz Ferreira, João Henrique Almeida Costa, Giancarlo Domingues, João Paulo Bacellar Costa Lima, José Antônio Veiga Sanhudo, Miguel Viana Pereira Filho
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:Autologous grafting is widely used in orthopedic surgery because of its high osteogenic capacity, immunologic compatibility, for the absence of risk of disease transmission, and for not requiring a bone bank. The posterior-superior calcaneal tuberosity is an option for obtaining a cortical and cancellous structural bone. This study aims to describe the operative technique and complications observed at the donor site of the posterior-superior calcaneal tuberosity.Methods:Patients who underwent graft harvesting from the posterior-superior calcaneal tuberosity were retrospectively evaluated by pain outcomes, imaging tests, and intra- and postoperative complications.Results:Twenty patients with a median age of 69 years (range 48-77) and follow-up of 16 months (12-26) were assessed. Median postoperative pain at the donor site was 0 (0-6), with 2 patients reporting persistent local pain. No case of Achilles tendon rupture or intra- or postoperative calcaneal fracture were identified. One patient developed a superficial infection that was quickly resolved using oral antibiotic therapy.Conclusion:The posterior-superior calcaneal tuberosity is an alternative source of autologous graft with low donor site morbidity.Level of EvidenceLevel IV, case series.
      Citation: Foot & Ankle International
      PubDate: 2021-07-31T05:30:37Z
      DOI: 10.1177/10711007211032665
       
  • Joint Preservation Surgery for Varus Ankle Arthritis with Large Talar Tilt

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      Authors: Chul Hyun Park, Ji Beom Kim, Jaeyoung Kim, Young Yi, Woo-Chun Lee
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:Varus ankle arthritis with large talar tilt (TT) is a challenging condition when considering joint preservation surgery. Three-dimensional deformity of the talus has been demonstrated with weightbearing computed tomography in varus ankle arthritis with large TT. The aim of this study was to investigate the clinical and radiographic results of posterior tibial tendon (PTT) transfer generally combined with bony realignment for varus ankle arthritis with large TT in nonparalytic ankle arthritis and to determine the indications for PTT transfer.Methods:This study includes 23 ankles with varus arthritis and TT larger than 7.5 degrees. Patients were categorized into improved (19 ankles) and unimproved (4 ankles) groups according to the postoperative clinical results at the last follow-up. Clinical and radiographic results were compared between the groups. A cut-off point for preoperative TT that indicated a borderline between improved and unimproved groups was determined to suggest the appropriate indication for joint preservation surgery.Results:In the improved group, TT, radiographic stage, Meary angle, and hindfoot alignment significantly improved at 6 months after surgery and were maintained at the last follow-up. In the unimproved group, the radiographic parameters mentioned above did not improve at 6 months after surgery, and TT decreased to 0.8 degrees as radiographic stage had progressed to end-stage arthritis at the last follow-up. In this small series, the cut-off point for predicting failure of surgery was 14.3 degrees of preoperative TT.Conclusion:PTT transfer often combined with bony realignment procedures may be a reasonable option for treating painful varus ankle arthritis with TT less than 14 degrees and hindfoot varus.Level of Evidence:Level IV, case series.
      Citation: Foot & Ankle International
      PubDate: 2021-07-28T06:27:31Z
      DOI: 10.1177/10711007211027290
       
  • Outcomes of Tibialis Anterior Tendon Reconstruction with Autograft or
           Allograft

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      Authors: Octavian Andronic, Ines Unterfrauner, Lukas Jud, Benjamin Fritz, Arnd F. Viehöfer, Stefan Fröhlich, Florian B. Imhoff, Stephan H. Wirth
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:In cases of tibialis anterior tendon (TAT) ruptures associated with significant tendon defect, an interposition graft is often needed for reconstruction. Both auto- and allograft reconstructions have been described in the literature. Our hypothesis was that both graft types would have a good integrity and provide comparable outcomes.Methods:Patients who underwent TAT reconstruction using either an auto- or allograft were identified. Patient-reported outcomes (PROs) were collected using the 12-Item Short Form Health Survey (SF-12) questionnaire, the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, the Foot Function Index (FFI), and the Karlsson-Peterson score. Functional outcome was assessed by isokinetic strength measurement. Outcomes were further assessed with magnetic resonance imaging (MRI) evaluation of graft integrity. All measurements were also performed for the contralateral foot.Results:Twenty-one patients with an average follow-up of 82 months (20-262 months), comprising 12 allograft and 9 autograft TAT reconstructions, were recruited. There were no significant differences in patient-reported outcomes between allograft reconstructions and autografts: SF-12 (30.7 vs 31.1, P = .77); AOFAS (83 vs 91.2, P = .19); FFI (20.7% vs 9.5%, P = .22); and Karlsson-Peterson (78.9 vs 87.1, P = .23). All grafts (100%) were intact on MRI with a well-preserved integrity and no signs of new rupture. There were no major differences in range of motion and functional outcomes as measured by strength testing between the operative and nonoperative side.Conclusion:Reconstructions of TAT achieved good PROs, as well as functional and imaging results with a preserved graft integrity in all cases. There were no substantial differences between allograft and autograft reconstructions.Level of Evidence:Level IV, retrospective case series.
      Citation: Foot & Ankle International
      PubDate: 2021-07-26T11:26:24Z
      DOI: 10.1177/10711007211029956
       
  • Clinical and Radiographic Outcomes of Percutaneous Chevron-Akin
           Osteotomies for the Correction of Hallux Valgus Deformity

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      Authors: Christopher M. Mikhail, Jonathan Markowitz, Luca Di Lenarda, Javier Guzman, Ettore Vulcano
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:Hallux valgus is a common cause of pain and dysfunction of the foot, sometimes requiring surgical correction when conservative measures fail. Although there are many methods of correction, one of the newer techniques is minimally invasive chevron-Akin (MICA). The aim of the current study is to evaluate clinical and radiographic effectiveness of MICA and narcotic use in a large patient cohort.Methods:All patients in this retrospective study were treated by a single fellowship-trained foot and ankle orthopedic surgeon. Patient demographics were collected for all cases. Preoperative and postoperative intermetatarsal angle (IMA) and hallux valgus angle (HVA) were measured in all patients on weightbearing 3-views radiographs. The Foot Function Index (FFI) was obtained pre- and postoperatively at each visit. All patients were prescribed regular use of ibuprofen for 3 days with acetaminophen and oxycodone reserved for breakthrough pain. Use of narcotic pain medication was recorded.Results:A total of 274 feet in 248 patients were included in the study. Overall, 87.9% were female and 12.1% were male. The mean preoperative IMA and HVA were 13.4 and 29.1 degrees, respectively. The postoperative IMA and HVA were 4.9 and 8.9 degrees, respectively. The mean FFI score part A was 92 preoperatively and 43 postoperatively. Patient satisfaction was 91.6%. The mean postoperative 5 mg oxycodone pill consumption was 2.2.Conclusion:MICA is good method to correct hallux valgus deformity with low postoperative narcotic use.Level of Evidence:Level III, this is a restrospective cohort study of a single surgeon practice.
      Citation: Foot & Ankle International
      PubDate: 2021-07-23T06:39:01Z
      DOI: 10.1177/10711007211031218
       
  • Outcomes of 2B Adult Acquired Flatfoot Deformity Correction in Patients
           With and Without Spring Ligament Tear

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      Authors: Steven M. Raikin, Ryan G. Rogero, Jared Raikin, Daniel O. Corr, Justin Tsai
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:It is currently unclear how injury to the spring ligament (SL) affects the preoperative presentation of adult acquired flatfoot deformity (AAFD) or the outcome of operative reconstruction. The purposes of this study were to assess the preoperative features and pre- or postoperative function of patients who underwent direct operative repair of an SL tear compared to those without a tear.Methods:86 patients undergoing operative correction of grade 2B AAFD by a single fellowship-trained foot and ankle orthopedic surgeon were reviewed at an average follow-up of 45.9 months. There were 35 feet found to have an SL tear that underwent concomitant debridement and direct repair of the SL. Patient charts were reviewed for demographic information, preoperative visual analog scale (VAS) pain level, and their Foot and Ankle Ability Measure (FAAM) activities of daily living (ADL) and sports subscales. Preoperative radiographic parameters were assessed. Patient outcomes of VAS pain, FAAM-ADL, and FAAM-Sports were collected and compared between groups.Results:Those with an SL tear had significantly lower FAAM-ADL and sports scores, with higher VAS pain scores preoperatively. Patient age, talonavicular uncoverage percentage, and talonavicular angle were found to be associated with spring ligament degeneration. At final follow-up, patients demonstrated a significant improvement in all outcome parameters, with no statistical difference found with patient satisfaction, final postoperative VAS pain, FAAM-ADL, or FAAM-Sports in those requiring a repair of their SL as compared to the control group.Conclusion:Increasing patient age, increasing talonavicular uncoverage percentage, and decreasing talonavicular angle are all independently associated with increased likelihood of patients with AAFD having an SL tear. At follow-up for operative treatment of grade 2B AAFD flatfoot with our approach, we found no clinical outcomes difference between those without SL tears and those with SL tears treated with concomitant SL debridement and repair.Level of Evidence:Level III, retrospective cohort study.
      Citation: Foot & Ankle International
      PubDate: 2021-07-23T06:37:19Z
      DOI: 10.1177/10711007211027270
       
  • Calcaneal Reconstruction With Free Deep Circumflex Iliac Artery
           Osseocutaneous Flap Following Aggressive Benign Bone Tumor Resection

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      Authors: Mohamad Aizat Rosli, Wan Faisham Wan Ismail, Wan Azman Wan Sulaiman, Nor Azman Mat Zin, Syurahbil Abdul Halim, Fatimah Mat Johar, Arman Zaharil Mat Saad, Ahmad Sukari Halim
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:Advances in limb-salvage techniques have made total calcanectomy and primary reconstruction possible in managing calcaneal aggressive benign tumors and selected cases of intraosseous malignant tumors. However, there is still no consensus on the operative approach, oncologic margin, and the best reconstruction method to date. These 2 cases describe our experience in calcaneal reconstruction with the free deep circumflex iliac artery (DCIA) osseocutaneous flap in benign aggressive calcaneal tumors.Methods:We reported 2 consecutive male and female patients, with an average age of 25 years (age 19 and 31, respectively), who underwent total calcanectomy and primary calcaneal reconstruction with the free DCIA osseocutaneous flaps for calcaneal chondroblastoma and giant cell tumor. A marginal resection of the entire calcaneus through the subtalar and calcaneocuboid joints (intra-articular approach) was performed in the first case and a wide local resection leaving 1 cm normal calcaneal bone margin anterosuperiorly (intraosseous approach) was performed in the second case.Results:The follow-up period averaged 48 months. Negative oncologic margins were achieved in both cases. The first case was complicated with venous thrombosis; however, the graft remained viable after emergency reexploration. Normal foot function was restored with good solid osseous union and bony hypertrophy observed. Both patients achieved good short-term functional and aesthetic outcomes with no donor site pain or disability. No local recurrence was reported either.Conclusion:Primary calcaneal reconstruction with the free DCIA osseocutaneous flap can lead to good short-term functional and aesthetic outcomes.Level of Evidence:Level IV, case series.
      Citation: Foot & Ankle International
      PubDate: 2021-07-21T11:15:36Z
      DOI: 10.1177/10711007211025280
       
  • Randomized Trial of Dilute Povidone-Iodine Soak and Scrub for Orthopedic
           Foot and Ankle Surgery

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      Authors: Nasima Mehraban, Connor Wakefield, David Rossi, Johnny Lin, Simon Lee, Kamran S. Hamid, Daniel D. Bohl
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:There is no consensus as to which skin antiseptic solution is most effective at reducing infection following orthopedic foot and ankle surgery. The purpose of this study is to determine if the addition of a dilute povidone-iodine soak and scrub to a standard preparation with alcohol and chlorhexidine decreases positive bacterial culture rates from the hallux nailfold.Methods:In this prospective, randomized controlled trial, 242 subjects undergoing orthopedic foot and ankle surgery were randomized to one of 2 groups. The control group received our standard 2-step skin antiseptic preparation of an alcohol scrub (step 1) followed by chlorhexidine/alcohol paint (step 2). The intervention group received a 3-minute dilute povidone-iodine soak and scrub followed by that same standard 2-step skin preparation. Immediately before skin incision, culture swabs were taken from the hallux nailfold of both groups.Results:Of the 257 subjects enrolled and randomized, 242 (94.2%) completed the study, satisfying the a priori sample size requirement of 242 subjects. There were no crossovers between groups. There were no differences in baseline characteristics between groups (P> .05 for each). There was no difference in bacterial growth rates between groups (26.8% growth in the intervention group vs 26.9% growth in the control group, P = .991).Conclusion:The hallux nailfold is one of the most difficult to sterilize areas prior to orthopedic foot and ankle surgery. This randomized controlled trail found no benefit to adding a 3-minute dilute povidone-iodine soak and scrub to a standard skin preparation with alcohol and chlorohexidine.Level of Evidence:Level I, randomized controlled trial.
      Citation: Foot & Ankle International
      PubDate: 2021-07-20T10:39:42Z
      DOI: 10.1177/10711007211025263
       
  • Patient Pain and Function After Correction of Posterior Malleolar Malunion

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      Authors: Yaxing Li, Yu Chen, Xi Liu, Jun Chen, Tingjiang Gan, Hui Zhang
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:The management of an ankle malunion involving the posterior malleolus remains challenging, and only a few published studies described the operative treatment of complex posterior malleolar malunion. A transfibular approach allows for direct visualization of the articular reduction of the posterior malleolus, but the reports of its use for correcting posterior malleolar malunion are rare. This study aims to evaluate the results of the intra-articular osteotomy via a transfibular approach for correcting an ankle malunion involving the posterior malleolus.Methods:We conducted a retrospective review of 26 patients with a symptomatic malunited ankle fracture involving posterior malleolus were treated with the intra-articular osteotomy via a transfibular approach in our department. Radiographic assessments were performed using plain radiographs and computed tomographic (CT) scans. Clinical outcomes were assessed using the AOFAS ankle-hindfoot score, visual analog scale (VAS), active range of motion of ankle, and the 36-Item Short-Form Health Survey score.Results:Postoperatively, anatomic correction of articular surface and anatomic reduction of syndesmosis were achieved in all patients as judged by CT scans. No evidence of progression had been found in 18 of 26 patients (69.2%) at final follow-up. The median AOFAS score improved from 42.0 to 81.5 (P < .001). Median pain VAS score decreased from 6.0 to 1.0 (P < .001). A favorable clinical outcome was associated with a short time interval from original injury to correction surgery and a lower grade of preoperative arthritis, but not with the posterior malleolar fragment size. However, time interval, the posterior malleolar fragment size, and the grade of preoperative arthritis showed no correlation with the progression of arthritis grade after surgery.Conclusion:An intra-articular osteotomy via a transfibular approach demonstrated an improved function and pain after operative treatment of malunited ankle fracture with a displaced posterior malleolar fragment.Level of Evidence:Level IV, retrospective case series.
      Citation: Foot & Ankle International
      PubDate: 2021-07-02T06:47:08Z
      DOI: 10.1177/10711007211017831
       
  • Outcomes of Posterior Arthroscopic Subtalar Arthrodesis for Medial Facet
           Talocalcaneal Coalition

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      Authors: Daniel Saraiva, Markus Knupp, André Sá Rodrigues, Tiago Mota Gomes, Xavier Martin Oliva
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:Medial facet talocalcaneal coalition can be a painful condition. This study aimed to determine clinical and radiographic outcomes of posterior arthroscopic subtalar arthrodesis (PASTA) for adult patients presenting with symptomatic medial facet talocalcaneal coalition and normal hindfoot alignment, with a minimal follow-up of 18 months.Methods:Between June 2017 and July 2019, this procedure was performed on 8 feet (8 patients; mean age, 55 [42-70] years; mean BMI, 29.8 [24.4-45.0] kg/m2). Clinical assessment was performed using Visual Analog Scale for Pain (VAS-P), Foot and Ankle Outcome Score (FAOS) and the 36-Item Short-Form Health Survey (SF-36). Patient satisfaction was assessed at the last available follow-up as “very satisfied”, “satisfied” or “unsatisfied”. Radiographic analysis was performed using plain radiography, computed tomography (CT) scan and magnetic resonance imaging (MRI). The primary outcome was to determine both clinical and radiographic outcomes.Results:The mean follow-up was 25.1 (18.2-34.2) months. The authors found statistically significant improvement on all clinical scores (VASP-P, FAOS and SF-36). They registered 6 “very satisfied” patients, 2 “satisfied” patients and no “unsatisfied” patient. Fusion of the subtalar joint was observed in all patients by 12 weeks and in 5 of them as soon as 8 weeks postoperatively (mean, 9.5 [8-12] weeks). There were no cases of delayed fusion or nonunion of the subtalar joint, superficial or deep infection, neurovascular damage, thromboembolic event, screw breakage, need for hardware removal or revision surgery.Conclusion:This study found that PASTA is a safe and reliable technique for adult patients presenting with symptomatic medial facet talocalcaneal coalition and normal hindfoot alignment, demonstrating and maintaining clinical improvement at an average follow-up of 2 years.Level of Evidence:Level IV, case series.
      Citation: Foot & Ankle International
      PubDate: 2021-07-01T08:58:39Z
      DOI: 10.1177/10711007211027289
       
  • Anatomic and Radiographic Safe Zone for Posterior Malleolar Screw
           Placement

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      Authors: Caroline Williams, Kaveh Momenzadeh, Max Michalski, John Y. Kwon, Ara Nazarian, Christopher P. Miller
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:The most appropriate treatment and management of posterior malleolar fractures (PMFs) lacks consensus. Indirect reduction and fixation with posterior to anterior (PA) screw shows promise by avoiding the risks associated with direct reduction or indirect anterior to posterior approaches. Some authors have raised concerns about potential risk to nearby structures with the PA technique, including hardware prominence into the syndesmosis. This study highlights use of the posteromedial vertical syndesmotic line (PVSL) as a fluoroscopic landmark, helping surgeons avoid intrasyndesmotic placement. Study aims are to evaluate PVSL correspondence with posterior border of the incisura tibialis and to define a safe zone between this line and flexor hallucis longus tendon.Methods:Indirect PA screw placement was completed on 10 cadaveric specimens, followed by fluoroscopy in mortise and lateral views. Dissection was performed to assess screw placement relative to the posteromedial border of the syndesmosis. The posterior border of the syndesmosis was marked with a radiopaque wire. Repeat imaging was completed to validate the fluoroscopic PVSL is representative of the posteromedial border of the tibial incisura.Results:On dissection, 9 out of 10 cadavers had accurate screw placement with no penetration into the syndesmosis. Corresponding imaging showed the screw head to be medial to the marker on mortise view. For the specimen with penetration into the syndesmosis, imaging confirmed that the screw head was lateral to the marker on mortise views. The radiopaque marker correlated with the PVSL for all specimens when comparing anatomic to radiographic findings. A radiographic safe zone is defined for the PA screw 12 mm medial to the PVSL to ensure no iatrogenic injury to the flexor hallucis longus tendon.Conclusion:This study demonstrated that a posterior incisura tibialis fluoroscopic landmark is unambiguous in localizing the posterior syndesmotic border and that screws medial to this line are safely out of the syndesmosis, while screws placed lateral are either in or at risk of intrasyndesmotic placement. A safe zone is defined for screw placement.Clinical Relevance:This article describes a radiographic and clinical safe zone for fixation and hardware placement during open reduction internal fixation (ORIF) of PMFs. This information will assist surgeons in avoiding intrasyndesmotic hardware placement as well as injury to deep soft tissue structures.
      Citation: Foot & Ankle International
      PubDate: 2021-07-01T08:57:25Z
      DOI: 10.1177/10711007211022747
       
  • The Hallux Metatarsophalangeal Capsule: An Anatomic Study With Respect to
           Percutaneous Hallux Valgus Correction

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      Authors: Kenneth M. Chin, Nicholas S. Richardson, John T. Campbell, Clifford L. Jeng, Matthew W. Christian, Rebecca A. Cerrato
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:Minimally invasive surgery for the treatment of hallux valgus deformities has become increasingly popular. Knowledge of the location of the hallux metatarsophalangeal (MTP) proximal capsular origin on the metatarsal neck is essential for surgeons in planning and executing extracapsular corrective osteotomies. A cadaveric study was undertaken to further study this anatomic relationship.Methods:Ten nonpaired fresh-frozen frozen cadaveric specimens were used for this study. Careful dissection was performed, and the capsular origin of the hallux MTP joint was measured from the central portion of the metatarsal head in the medial, lateral, dorsal, plantarmedial, and plantarlateral dimensions.Results:The ten specimens had a mean age of 77 years, with 5 female and 5 male. The mean distances from the central hallux metatarsal head to the MTP capsular origin were 15.2 mm dorsally, 8.4 mm medially, 9.6 mm laterally, 19.3 mm plantarmedially, and 21.0 mm plantarlaterally.Conclusion:The MTP capsular origin at the hallux metatarsal varies at different anatomic positions. Knowledge of this capsular anatomy is critical for orthopedic surgeons when planning and performing minimally invasive distal metatarsal osteotomies for the correction of hallux valgus.Type of Study:Cadaveric Study.
      Citation: Foot & Ankle International
      PubDate: 2021-06-30T10:24:15Z
      DOI: 10.1177/10711007211027262
       
  • Association of Visual Appearance on Outcomes After Hallux Valgus Surgery

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      Authors: Hakan Bahar, Kadir Ilker Yildiz
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:In this study, our aim was to determine the effect of cosmetic improvement on patient satisfaction and functional scores in hallux valgus (HV) surgery.Methods:Preoperative foot photographs of 105 patients who had undergone chevron osteotomy for HV between 2016 and 2018 were taken. The patients were divided into 2 groups. Twenty-four months after surgery, the preoperative foot photographs were shown to patients in group 1 (n = 52) but not to patients in group 2 (n = 53). The groups were then compared using the visual analog scale (VAS), the American Orthopaedic Foot & Ankle Society Hallux Metatarsophalangeal-Interphalangeal (AOFAS Hallux MTP-IP), and the 36-Item Short Form Health Survey (SF-36) scores. Both groups were evaluated radiologically with preoperative and postoperative hallux valgus angles and intermetatarsal angles.Results:There was no difference between the 2 groups in terms of radiologic parameters either pre- or postoperatively, or AOFAS Hallux MTP-IP scores postoperatively. However, for group 1, the VAS was lower (0.4±0.8 vs 1.8±1.6, P = .003) and both the SF-36 physical functioning (88.3±18.1 vs 79.1±23.2, P = .017) and SF-36 mental health scores were higher (78.8±19 vs 69.2±16.3, P = .022).Conclusion:Visualizing improvement in the cosmetic appearance of the foot appears associated with patients’ perception of subjective pain and functional improvement. We recommend that preoperative foot photographs be taken and recorded.Level of Evidence:Level III, case-control study.
      Citation: Foot & Ankle International
      PubDate: 2021-06-30T10:21:54Z
      DOI: 10.1177/10711007211019940
       
  • Midterm Outcomes of Unstable Ankle Fractures in Young Patients Treated by
           Closed Reduction and Fixation With an Intramedullary Fibular Nail vs Open
           Reduction Internal Fixation Using a Lateral Locking Plate

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      Authors: Duk-hwan Kho, Byung-Ki Cho, Seung-Myung Choi
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:We aimed to compare 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 the locking plate 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 3-dimensional (3D)–reconstructed computed tomography as well as the development of posttraumatic osteoarthritis (PTOA) of the ankle assessed by weightbearing plain radiography. Clinical evaluation included the American Orthopaedic Foot & Ankle Society hindfoot score, Olerud and Molander Score, the Foot and Ankle Outcome Score, and visual analog scale pain score as well as complications.Results:At median follow-up greater than 4 years, we found no significant differences in measured 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). However, we did find a greater proportion of radiographically fair or poor reductions in the IMN group than in the ORIF group (P < .001). The poor reductions in the IMN group were primarily related to Weber type C, pronation-type injury, and comminuted fibular and trimalleolar fractures (P < .001). PTOA was also more frequently observed in the IMN group than in the ORIF group (21.3% vs 9.1%, P = .024).Conclusion:Given the current prevailing technologies for fracture fixation, this study suggests that 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.Level of Evidence:Level III, retrospective comparative study.
      Citation: Foot & Ankle International
      PubDate: 2021-06-29T12:34:19Z
      DOI: 10.1177/10711007211017470
       
  • Assessing the Rotation of the First Metatarsal on Computed Tomography
           Scans: A Systematic Literature Review

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      Authors: Ali-Asgar Najefi, Karan Malhotra, Shelain Patel, Nicholas Cullen, Matthew Welck
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:Hallux valgus is a multiplanar deformity that is often treated on the basis of 2-dimensional (2D) parameters and radiographs. Recurrence rates after surgical correction remain high, and failure to correct pronation of the metatarsal is increasingly stipulated as being part of the problem. Multiple methods of assessing metatarsal pronation have been proposed.Methods:We performed a systematic literature review identifying studies that measured metatarsal pronation and torsion on computed tomography (CT) scans. Specific methodology, patient groups, results, and reliability assessments were all reported.Results:We identified 14 studies that fulfilled the inclusion criteria. Eleven studies measured 2D values on CT scan, and 3 studies used computer-based 3-dimensional (3D) modeling and artificial intelligence systems to help calculate pronation. Metatarsal pronation angle, α angle, sesamoid rotation angle, and measurements for torsion were the most commonly used methods. All angles and measurements were performed as 2D measurements, but the metatarsal pronation angle was also performed with 3D modeling. Reliability and reproducibility of the α angle and metatarsal pronation angle were excellent, despite being performed on studies with small numbers.Conclusion:Multiple methods have been reported to demonstrate first metatarsal pronation on CT, of which the α angle and the metatarsal pronation angle are the most pragmatic and useful in a clinical setting. Further work is needed to further validate the reliability of these measurements in larger series and to identify normal pronation and metatarsal torsion on weightbearing imaging. Further work is required to determine whether addressing pronation reduces recurrence rates and improves outcomes in surgery for hallux valgus.Level of Evidence:Level III
      Citation: Foot & Ankle International
      PubDate: 2021-06-25T06:36:25Z
      DOI: 10.1177/10711007211020676
       
  • Patient-Reported Outcomes of Surgically Treated Insertional Achilles
           Tendinopathy

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      Authors: Hubert Hörterer, Sonja Oppelt, Wolfgang Böcker, Oliver Gottschalk, Norbert Harrasser, Markus Walther, Hans Polzer, Sebastian Felix Baumbach
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:The aim of this study was to assess the patient-reported outcome measures (PROMs) in patients with insertional Achilles tendinopathy (IAT) treated surgically by debridement of all pathologies through a midline-incision trans-achillary approach (MITA).Methods:This is a retrospective cohort study with current follow-up. Patients treated surgically by a MITA, addressing all pathologies of IAT, with at least 12 months of follow-up were included. Demographics, medical history, surgical details, and complications were recorded. Patient-reported outcomes were assessed using the Foot Function Index (FFI), Victorian Institute of Sport Assessment–Achilles questionnaire (VISA-A-G), visual analog scale foot and ankle (VAS-FA), and 12-Item Short-Form Health Survey (SF-12). Longitudinal FFI data were available for 48% of the patients.Results:A total of 118 patients (63.4%) with a mean follow-up of 50 ± 25 months were included. The FFI improved from 53 (24) preoperatively to 2 (11) points at the final follow-up. The final VISA-A-G score was 93 (26), the VAS-FA score 93 (15), the SF-12 Physical Component Summary 56 (8), and the SF-12 Mental Component Summary 55 (12) points. There was an additional FFI improvement between 12 months and the final follow-up. Up to 47% (VISA-A-G) of patients had residual symptoms. A postoperative shoe conflict was the only parameter negatively affecting the PROMs (P < .001).Conclusion:Addressing all pathologies of IAT by the MITA resulted in overall good postoperative PROMs after 4 years. But up to 47% of patients remained impaired. The only parameter correlating with an impaired PROM was a postoperative shoe conflict.Level of Evidence:Level IV, retrospective cohort study.
      Citation: Foot & Ankle International
      PubDate: 2021-06-22T07:31:25Z
      DOI: 10.1177/10711007211023060
       
  • Low Rate of Peri-implant Osteolysis in Trabecular Metal Total Ankle
           Replacement on Short- to Midterm Follow-up

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      Authors: Sami Kormi, Ia Kohonen, Helka Koivu, Hannu Tiusanen
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:Peri-implant osteolysis is one of the major complications related to total ankle replacement. The aim of this study was to investigate the short- to midterm incidence of peri-implant osteolysis using computed tomography (CT) as imaging method for the Trabecular Metal Total Ankle (TMTA) implant representing a novel total ankle replacement (TAR) implant design regarding material and surgical technique.Methods:In total, 104 consecutive patients who had a primary TMTA replacement between March 2013 and October 2017 were included in the study. The radiographic evaluation included weightbearing anteroposterior and lateral views at baseline and after 3, 6, and every 12 months postoperatively. A helical CT was undertaken preoperatively and of the 80 patients available to follow up at least 12 months postoperatively, with average time interval between the TAR operation and the latest CT of 39 (range, 12-85) months.Results:Eight of 80 patients had altogether 11 osteolytic lesions around the components on CT images. Seven lesions were found in tibia, 3 in talus, and 1 in distal fibula. Four of the tibial lesions were situated in the medial malleolus and were not in contact with the prosthesis component. The sizes of the osteolytic lesions ranged between 7 and 20 mm, and the average volume of the lesions was 689 mm3.Conclusion:We conclude that the risk of peri-implant osteolysis with the TMTA implant is minimal in short to midterm. The anatomic configuration, unique material, and surgical technique may all contribute to the TMTA implant having a low rate of peri-implant osteolysis.Level of Evidence:Level IV, case series.
      Citation: Foot & Ankle International
      PubDate: 2021-06-18T11:32:40Z
      DOI: 10.1177/10711007211017468
       
  • Treatment of Severe Rigid Posttraumatic Equinus Deformity With Gradual
           Deformity Correction and Arthroscopic Ankle Arthrodesis

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      Authors: Patricio Fuentes, Natalio Cuchacovich, Paulina Gutierrez, Maximiliano Hube, Gonzalo F. Bastías
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:Posttraumatic ankle equinus is associated with rigid deformity, poor skin condition, and multiple prior surgeries. Open acute correction has been described using osteotomies, talectomy, and arthrodesis, but concerns exist about skin complications, neurologic alterations, secondary limb discrepancy, and bone loss. Gradual correction using a multiplanar ring fixator and arthroscopic ankle arthrodesis (AAA) may decrease these complications.Methods:We retrospectively reviewed patients undergoing correction of posttraumatic rigid equinus with at least 1 year of follow-up after frame removal. The procedure consisted of percutaneous Achilles lengthening, gradual equinus correction using a multiplanar ring fixator, and AAA retaining the fixator in compression with screw augmentation. Frame removal depended on signs of union on the computed tomography scan. Visual analog scale (VAS) and Foot Function Index (FFI) scores were assessed as well as preoperative and postoperative x-rays. Complications were noted throughout the follow-up period.Results:Five patients were treated with a mean age of 35 years and mean follow-up of 31 months. Deformities were gradually corrected into a plantigrade foot over an average duration of 6 weeks. Union was achieved in all patients with a mean time of an additional 25 weeks, for a mean total frame time of 31 weeks. The mean preoperative tibiotalar angle was 151 degrees and was corrected to 115 degrees. FFI score improved from a mean of 87 to 24 and VAS from 8 to 2.Conclusion:Posttraumatic rigid equinus can be treated effectively using gradual correction followed by integrated AAA in a safe and reproducible manner. Patients in this series had excellent functional, radiological, and satisfaction results.Level of Evidence:Level IV, retrospective case series.
      Citation: Foot & Ankle International
      PubDate: 2021-06-18T11:32:25Z
      DOI: 10.1177/10711007211018201
       
  • Staged Management of Severely Displaced Calcaneal Fractures With
           Transarticular Pinning: A Damage Control Strategy

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      Authors: Kyeong-Hyeon Park, Chang-Wug Oh, Joon-Woo Kim, Hee-June Kim, Dong-Hyun Kim, Tae-Seong Kim
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:Severely displaced calcaneal fractures can result in considerable morphology derangement and may be accompanied by soft tissue compromise. Delayed operative restoration of the calcaneal morphology may result in acute retensioning of the damaged soft tissue with associated wound-related complications. In this study, we describe a staged treatment of displaced intra-articular calcaneal fractures that uses temporary transarticular Kirschner wire (K-wire) fixation and staged conversion to definite fixation.Methods:We identified all of the patients who were treated at our institution for calcaneal fractures between 2015 and 2019. A total of 17 patients with 20 calcaneal fractures were selectively treated with 2-stage management. Temporary transarticular K-wire fixation was performed 24 hours after the injury to restore calcaneal morphology and the surrounding soft tissue. After the soft tissue was considered safe, delayed open reduction and internal fixation was performed. The time to definite surgery, radiographic alignment, wound complications, time to radiographic union, and hindfoot American Orthopaedic Foot & Ankle Society (AOFAS) scores were recorded.Results:The average follow-up period was 17 months (range, 12-43). The average Böhler angle increased from a mean of −22 degrees (range, −109 to 25) to 25 degrees (range, 0 to 47) after temporary transarticular K-wire fixation. The mean time from temporary pinning to conversion to definite internal fixation was 20 (range, 10-32) days. There were no immediate postoperative complications. The average time to radiographic union was 13.7 (range, 10-16) weeks. The mean AOFAS score was 87 (range, 55-100). No infections or wound complications were reported during the follow-up period.Conclusion:Temporary transarticular pinning for staged calcaneal fracture treatment is safe and effective in restoring the calcaneal morphology. This novel and relatively simple method may facilitate delayed operation and decrease wound-related complications.Level of Evidence:Level IV, retrospective case series.
      Citation: Foot & Ankle International
      PubDate: 2021-06-16T07:24:08Z
      DOI: 10.1177/10711007211013012
       
  • Distal Tibial Reconstruction in the Management of Primary Bone Tumors in
           Children and Adolescents

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      Authors: Anna Raciborska, Katarzyna Bilska, Iwona Malesza, Carlos Rodriguez-Galindo, Bartosz Pachuta
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:Distal tibial primary bone tumors are rare, and options for limb salvage surgery are limited and challenging. Importantly, local control has shown to be crucial and necessary for cure, and radical surgery is one of the most important components of therapy for some bone sarcomas. We investigated the feasibility and functional and oncological outcomes of distal tibial reconstruction using endoprosthesis in children with malignant bone tumors.Methods:Fourteen patients (median age 13.6 years) with primary bone tumors (4 Ewing sarcoma [ES], 10 osteosarcoma) of the distal tibiae were treated during 2013-2019. All patients had reconstruction using a modular (13 patients) or expandable custom-made titanium bone replacement system (1 patient). All patients received chemotherapy before and after surgery.Results:Twelve patients (85.7%) are alive with a median follow-up 20 months from diagnosis. Five-year estimates of event-free survival and overall survival were 60.6% and 76.4%, respectively. Three patients had postoperative complications requiring second surgery. Maximum dorsiflexion and plantar flexion of the foot were 20 degrees (range 0-20 degrees) and 20 degrees (range 5-20 degrees), respectively.Conclusion:For select distal tibial sarcomas, after neoadjuvant chemotherapy pretreatment and radical resection, reconstruction using an endoprosthesis as a radical surgery provides an option was associated with a low rate of short-term local complications and relatively good early function.Level of Evidence:Level IV, therapeutic study.
      Citation: Foot & Ankle International
      PubDate: 2021-06-12T06:48:49Z
      DOI: 10.1177/10711007211012690
       
  • Long-term Patient-Reported Outcome Measures Following Particulated
           Juvenile Allograft Cartilage Implantation for Treatment of Difficult
           Osteochondral Lesions of the Talus

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      Authors: Joseph Manzi, Artine Arzani, Mathew J. Hamula, Kshitij Manchanda, Dinesh Dhanaraj, Cary B. Chapman
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:Conventional methods are not suitable for difficult to treat osteochondral lesions of the talus (OCLTs). The role of particulated juvenile allograft articular cartilage implantation is not well elucidated for long-term patient outcomes.Methods:Thirteen patients with difficult-to-treat OCLTs underwent arthroscopy-assisted implantation of particulated juvenile articular cartilage graft into defects from 2010 to 2012 by the same surgeon. “Difficult to treat” was defined as having at least 3 of the following features or 2 if both variables described lesion characteristics: (1) lesions size of 107 mm2 or greater, (2) shoulder lesions, (3) patients who failed microfracture, (4) patient aged ≥40 years, or (5) patient body mass index (BMI)>25. Patients were evaluated using physical examination, patient interviews, and outcome score measures. Patients had follow-up at 2 years, 4 years, and between 6 and 10 years at their most recent follow-up. Differences in functional outcome scores were compared before and after surgery.Results:Patients (age: 46.5 ± 11.8 years, BMI: 28.5 ± 6.1) had, on average, most recent follow-up of 8.0 years (range 72-113 months). Average visual analog scale for pain score decreased for patients by 3.9 points (95% confidence interval [CI] 2.18-5.60), when compared to preoperative assessment. Foot and Ankle Ability Measure (FAAM) Activities of Daily Living (ADL) and Sports subscale scores also improved from 46.5 to 80.9 (95% CI 21.35-47.43), and from 18.8 to 57.9 (95% CI 21.05-57.10), respectively. Short Form–36 Health Survey physical component scores showed significant improvement by an average of 45.5 points (95% CI 32.42-58.50). American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Scale scores improved from 55.2 to 80.3 (95% CI 12.459-37.741).Conclusion:These results demonstrate positive patient-reported long-term outcomes for a cohort of patients with difficult OCLTs, followed over the course of 6-10 years after treatment with arthroscopy-assisted particulated juvenile articular cartilage implantation.Level of Evidence:Level II, prospective cohort study.
      Citation: Foot & Ankle International
      PubDate: 2021-06-11T07:30:26Z
      DOI: 10.1177/10711007211014173
       
  • Short-term Efficacy of Ultrasonographic Guidance for Intra-articular
           Corticosteroid Injection in Hallux Rigidus: A Single-Blind Randomized
           Controlled Trial

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      Authors: Seyede Zahra Emami Razavi, Mohaddeseh Azadvari, Hamid R. Fateh, Masood Ghahvechi Akbari, Shahrbanoo Kazemi, Elahe Rezaee
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:Multiple considerations should be taken before standardizing a clinical procedure such as efficacy, safety, or the cost. The aim of this study was to compare the effects of landmark-guided vs ultrasonography-guided intra-articular injection of corticosteroid into the first metatarsophalangeal joint cavity to reduce pain and dysfunction in patients with hallux rigidus.Methods:We carried out a single-blind randomized controlled trial with 2 parallel arms in an outpatient clinic affiliated with a medical university. In total, 50 participants (35 women) with the mean (SD) age of 49.8 (10.3) years were randomly allocated to landmark-guided or ultrasonography-guided groups (each n = 25). Each patient received a single intra-articular injection of 40-mg methylprednisolone plus 1 mL lidocaine into the affected first metatarsophalangeal joint. The primary outcome was joint pain and the secondary outcome was the American Orthopaedic Foot & Ankle Society score. We measured the outcomes at baseline and 2 and 6 weeks after the intervention.Results:Six weeks after the injections, there were no statistically significant differences between the study groups in pain reduction and increase in the American Orthopaedic Foot & Ankle Society scores (P = .131 and .241, respectively). We did not find any complications for the injections in both groups. There were statistically significant changes within each group in pain and the scores for the landmark (P < .001, and P = .007), and ultrasonography groups (both P < .001).Conclusion:Landmark guidance is as effective as ultrasonographic guidance for intra-articular injection in patients with hallux rigidus. A single intra-articular injection of 40 mg methylprednisolone plus 1 mL lidocaine is an efficient and safe therapeutic measure for decreasing joint pain and maintaining its function, at least for 6 weeks.Level of Evidence:Level I, high-quality prospective randomized study.
      Citation: Foot & Ankle International
      PubDate: 2021-06-11T07:29:33Z
      DOI: 10.1177/10711007211015988
       
  • Comparative Reliability of a Novel Electromechanical Device and Handheld
           Ruler for Measuring First Ray Mobility

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      Authors: Oliver J. Morgan, Rajshree Hillstrom, Robert Turner, Jonathan Day, Ibadet Thaqi, Kristin Caolo, Jinsup Song, Roland Russell, Scott Ellis, Jonathan T. Deland, Howard J. Hillstrom
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:Quantifying first ray mobility is crucial to understand aberrant foot biomechanics. A novel device (MAP1st) that can perform measurements of first ray mobility in different weightbearing conditions, foot alignments, and normalization was tested. The reliability of these measurement techniques was assessed in comparison to a handheld ruler considered representative of the common clinical examination.Methods:The study included 25 participants (50 feet). Two independent raters performed baseline, test-retest, and remove-replace measurements of first ray mobility with MAP1st and the handheld device. The effects of non-, partial, and full weightbearing in subtalar joint neutral and the resting calcaneal stance position were assessed. Measurement normalization relative to foot size was also investigated. Intra- and interclass correlation coefficients (ICCs) were calculated for each device between the 2 raters. In addition, Bland-Altman plots were constructed to determine if fixed biases or substantial outliers were present.Results:Similar intrarater ICC values were found for both devices (≥0.85). However, interrater ICC values were substantially improved by MAP1st compared with the handheld device (0.58 vs 0.06). Bland-Altman plots demonstrated biases of 1.27 mm for the handheld ruler, and 2.88 to 0.05 mm and −1.16 to 0.00 for linear and normalized MAP1st measurements, respectively. Improved reliability was achieved with MAP1st for normalized assessments of first ray mobility while the foot was placed in partial- and full-weightbearing resting calcaneal stance positions.Conclusion:MAP1st provided reliable assessments of partial- and full-weightbearing first ray mobility. It should help investigators to explore the potential relationships between first ray function and aberrant foot biomechanics in future research.Level of Evidence:Level II, prospective cohort study.
      Citation: Foot & Ankle International
      PubDate: 2021-06-11T07:29:19Z
      DOI: 10.1177/10711007211020345
       
  • Depression Following Operative Treatments for Achilles Ruptures and Ankle
           Fractures

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      Authors: Reid Davison, Jean-Philippe A. Daniel, Alexander J. Idarraga, Kathryn M. Perticone, Johnny Lin, George B. Holmes, Simon Lee, Kamran S. Hamid, Daniel D. Bohl
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:The sudden and debilitating nature of lower extremity injuries can trigger mood disturbances, including major depressive disorder.Methods:This prospective study enrolled patients undergoing operative repair of ankle fractures and Achilles ruptures and followed them for 1 year postoperatively. The validated Patient Health Questionnaire (PHQ-9) for depressive symptoms was administered at the preoperative visit and at postoperative weeks 1, 2, 4, 8, 16, 24, 32, 40, and 52. PHQ-9 is scored 0 to 27, with higher values indicating greater depression symptoms.Results:Fifty-eight patients completed 1 year of follow-up. The mean PHQ-9 score was 2.7 (range, 0-20) at the preoperative visit, peaked at postoperative week 1 (4.9; range, 0-16), and reached its low at postoperative week 52 (0.8; range, 0-7). Cumulative incidences of depressive symptoms during the first year following surgery were 51.7% for at least mild depression, 22.4% for at least moderate depression, and 6.9% for severe depression. A history of mental health disorder and the inability to work during the period of postoperative immobilization were independently associated with greater depressive symptoms.Conclusion:The majority of patients undergoing operative treatment of Achilles ruptures and ankle fractures develop postoperative symptoms of mild to moderate depression that normalize after several months. Patients with a history of mental health disorder or who cannot work while immobilized postoperatively are at greatest risk.Level of Evidence:Level II.
      Citation: Foot & Ankle International
      PubDate: 2021-06-10T10:45:02Z
      DOI: 10.1177/10711007211020346
       
  • 30-Day Outcomes for Total Ankle Arthroplasty in Patients With Anemia

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      Authors: Jordan R. Pollock, Matt K. Doan, M. Lane Moore, Jeffrey D. Hassebrock, Justin L. Makovicka, David G. Deckey, Todd A. Kile, Karan A. Patel
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:While anemia has been associated with poor surgical outcomes in total knee arthroplasty and total hip arthroplasty, the effects of anemia on total ankle arthroplasty remain unknown. This study examines how preoperative anemia affects postoperative outcomes in total ankle arthroplasty.Methods:A retrospective analysis was performed using the American College of Surgeons National Surgery Quality Improvement Project database from 2011 to 2018 for total ankle arthroplasty procedures. Hematocrit (HCT) levels were used to determine preoperative anemia.Results:Of the 1028 patients included in this study, 114 patients were found to be anemic. Univariate analysis demonstrated anemia was significantly associated with an increased average hospital length of stay (2.2 vs 1.8 days, P < .008), increased rate of 30-day readmission (3.5% vs 1.1%, P = .036), increased 30-day reoperation (2.6% vs 0.4%, P = .007), extended length of stay (64% vs 49.9%, P = .004), wound complication (1.75% vs 0.11%, P = .002), and surgical site infection (2.6% vs 0.6%, P = .017). Multivariate logistic regression analysis found anemia to be significantly associated with extended hospital length of stay (odds ratio [OR], 1.62; 95% CI, 1.07-2.45; P = .023) and increased reoperation rates (OR, 5.47; 95% CI, 1.15-26.00; P = .033). Anemia was not found to be a predictor of increased readmission rates (OR, 3.13; 95% CI, 0.93-10.56; P = .066) or postoperative complications (OR, 1.27; 95% CI, 0.35-4.56; P = .71).Conclusion:This study found increasing severity of anemia to be associated with extended hospital length of stay and increased reoperation rates. Providers and patients should be aware of the increased risks of total ankle arthroplasty with preoperative anemia.Level of Evidence:Level III, retrospective comparative study.
      Citation: Foot & Ankle International
      PubDate: 2021-06-10T10:44:01Z
      DOI: 10.1177/10711007211017512
       
  • Outcomes of Joint Preservation Surgery in Valgus Ankle Arthritis Without
           Deltoid Ligament Insufficiency

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      Authors: Jaeyoung Kim, Ji-Beom Kim, Woo-Chun Lee
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:To date, information about the role of proximal alignment correction in treating nontraumatic valgus ankle arthritis is limited. This study aimed to report outcomes of realignment surgery, including supramalleolar correction in valgus arthritic ankles without evidence of deltoid ligament insufficiency.Methods:Thirteen patients (13 ankles) who underwent joint preservation surgery for valgus ankle arthritis without evidence of deltoid ligament insufficiency were reviewed. Medial opening wedge supramalleolar osteotomy (n = 11) and varization supramalleolar dome osteotomy (n = 2) were performed to realign the hip-knee-ankle-hindfoot axis. Concomitant hindfoot correction was accompanied with either medial displacement calcaneal osteotomy (n = 8) or subtalar arthrodesis (n = 5). Pain, functional outcome (Foot Function Index [FFI]), radiographic arthritis grade (grades 0-4), 9 plain radiographic parameters, and 2 weightbearing computed tomography parameters were evaluated pre- and postoperatively. All patients completed a minimum 2-year follow-up.Results:Preoperatively, 10 ankles (77%) demonstrated a varus tibial plafond, and 3 ankles (23%) demonstrated a valgus or neutral tibial plafond. Postoperatively, radiographic arthritis grade improved in all except 1 patient, and the mean talar tilt angle improved from 5.5 to 1.7 degrees. The mean pain score (visual analog scale) decreased significantly from 7.3 to 2.5 (P < .05), and the mean FFI improved significantly from 57.7 to 18.6 (P < .001). None of the patients underwent conversion to joint-sacrificing procedures at the latest follow-up.Conclusion:This study demonstrated a possible relationship between lower limb malalignment and valgus ankle arthritis. Realignment surgery, including supramalleolar osteotomies, which straightens the mechanical axis and decreases the slope of the tibial plafond, may be a reasonable approach in joint preservation of valgus ankle arthritis without deltoid ligament insufficiency.Level of Evidence:Level IV, case series.
      Citation: Foot & Ankle International
      PubDate: 2021-06-10T10:43:35Z
      DOI: 10.1177/10711007211016001
       
  • Clinical and Patient-Reported Outcomes Following Peroneus Brevis
           Reconstruction With Hamstring Tendon Autograft

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      Authors: Bopha Chrea, Stephanie K. Eble, Jonathan Day, Oliver B. Hansen, Scott J. Ellis, Martin J. O’Malley, Mark C. Drakos
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:Peroneal tendon injuries are a common cause of lateral ankle pain and instability. While the use of hamstring autograft has been proposed as a viable surgical option for peroneus brevis reconstruction, reported outcomes with this technique are limited in the literature. We present patient-reported and clinical outcomes for patients who underwent peroneus brevis reconstruction with hamstring autograft.Methods:Thirty-one patients were retrospectively identified who underwent a procedure including peroneus brevis reconstruction with hamstring autograft for peroneal tendinopathy between February 2016 and May 2019. All patients who had a peroneus brevis reconstruction were included, and all concomitant procedures were noted. Patient-Reported Outcomes Measurement Information System (PROMIS) surveys were prospectively collected preoperatively and at a minimum of 1 year postoperatively (mean, 24.3; range, 12-52.7) months. Retrospective chart review was performed to evaluate the incidence of postoperative complications and reoperations.Results:When evaluating pre- and postoperative patient-reported outcome surveys (n = 26; 84%), on average, patients reported improvement in every PROMIS domain evaluated, with significant improvement in Physical Function (+5.99; P = .006), Pain Interference (–8.11; P < .001), Pain Intensity (–9.02; P < .001), and Global Physical Health (+7.29; P = .001). Three patients reported persistent pain at a minimum of 1 year postoperatively, of whom 2 required reoperation. No patient reported persistent pain or discomfort at the harvest site of the hamstring autograft.Conclusion:Patients undergoing peroneus brevis reconstruction with hamstring autograft experienced clinically significant improvement in patient-reported and clinical outcomes. Few postoperative complications were observed, and patients reported improvements across all patient-reported outcome domains, with significant improvements for pain and function domains. Reconstruction with hamstring autograft represents a viable surgical option in the setting of peroneal tendinitis or tears.Level of Evidence:Level IV, case series.
      Citation: Foot & Ankle International
      PubDate: 2021-06-10T10:43:15Z
      DOI: 10.1177/10711007211015186
       
  • Radiographic Outcomes of Cotton Osteotomy in Treatment of Adult-Acquired
           Flatfoot Deformity

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      Authors: Mostafa M. Abousayed, Michelle M. Coleman, Lawrence Wei, Cesar de Cesar Netto, Lew C. Schon, Gregory P. Guyton
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:We investigated the long-term radiographic outcomes of the Cotton osteotomy performed at our institution by the 2 senior authors in conjunction with other reconstruction procedures to correct adult-acquired flatfoot deformity (AAFD).Methods:We retrospectively studied patients who underwent Cotton osteotomy between 2005 and 2010 with minimum 4-year follow-up. Radiographic assessment was made on weightbearing radiographs taken at 4 different time intervals: preoperative, early (first postoperative full weightbearing), intermediate (between 1 and 4 years postoperatively), and final (over 4 years postoperatively).Results:Nineteen patients were included. Final follow-up was 8.6 ± 2.6 years. The lateral talus–first metatarsal angle improved significantly from preoperative to early radiographs (n = 15; mean change: 30 degrees, 95% CI, 21.6-38.7; P < .0001). A significant loss of correction was observed between intermediate and final radiographs (n = 11; mean change: 17 degrees, 95% CI, 8.1-26.4; P < .0001). Of 14 patients with early radiographs, 8 lost>50% of the correction initially achieved. Medial column height decreased by 3.0 mm (95% CI, 1.80-7.90; P = .35) between early radiographs and final follow-up.Discussion:This is the longest reported radiographic follow-up of the Cotton osteotomy performed to address forefoot varus deformity as part of AAFD. The Cotton osteotomy achieved radiographic correction of the medial longitudinal arch at early follow-up, but approximately half of the patients had lost over 50% of that correction at final follow-up. The lengthened angular shape of the cuneiform did not collapse, implying that further collapse occurred through the medial column joints.Level of Evidence:Level IV, case series.
      Citation: Foot & Ankle International
      PubDate: 2021-06-10T10:41:55Z
      DOI: 10.1177/10711007211015175
       
  • Assessment of Hindfoot Alignment Comparing Weightbearing Radiography to
           Weightbearing Computed Tomography

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      Authors: Christopher B. Arena, Yantarat Sripanich, Richard Leake, Charles L. Saltzman, Alexej Barg
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:Hindfoot alignment view (HAV) radiographs are widely utilized for 2-dimensional (2D) radiographic assessment of hindfoot alignment; however, the development of weightbearing computed tomography (WBCT) may provide more accurate methods of quantifying 3-dimensional (3D) hindfoot alignment. The aim of this study was to compare the 2D calcaneal moment arm measurements on HAV radiographs with WBCT.Methods:This retrospective cohort study included 375 consecutive patients with both HAV radiographs and WBCT imaging. Measurement of the 2D hindfoot alignment moment arm was compared between both imaging modalities. The potential confounding influence of valgus/varus/neutral alignment, presence of hardware, and motion artifact were further analyzed.Results:The intraclass correlation coefficients (ICCs) of interobserver and intraobserver reliability for measurements with both imaging modalities were excellent. Both modalities were highly correlated (Spearman coefficient, 0.930; P < .001). HAV radiographs exhibited a mean calcaneal moment arm difference of 3.9 mm in the varus direction compared with WBCT (95% CI, –4.9 to 12.8). The difference of hindfoot alignment between both modalities was comparable in subgroups with neutral/valgus/varus alignment, presence of hardware, and motion artifact.Conclusion:Both HAV radiographs and WBCT are highly reliable and highly correlated imaging methods for assessing hindfoot alignment. Measurements were not influenced by severe malalignment, the presence of hardware, or motion artifact on WBCT. On average, HAV radiographs overestimated 3.9 mm of varus alignment as compared with WBCT.Level of Evidence:Level III, retrospective comparative study.
      Citation: Foot & Ankle International
      PubDate: 2021-06-10T10:41:35Z
      DOI: 10.1177/10711007211014171
       
  • Evaluation of a Weightbearing CT Artificial Intelligence-Based Automatic
           Measurement for the M1-M2 Intermetatarsal Angle in Hallux Valgus

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      Authors: Jonathan Day, Cesar de Cesar Netto, Martinus Richter, Nacime Salomao Mansur, Celine Fernando, Jonathan T. Deland, Scott J. Ellis, François Lintz
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:Weightbearing cone beam computed tomography (WBCT) has been gaining traction as a useful imaging modality in the diagnosis and follow-up of foot and ankle musculoskeletal pathologies due to the ability to perform quick, low-dose, 3-dimensional (3D) scans. However, the resulting wealth of 3D data renders daily clinical use time-consuming. The aim of this study was to evaluate a new artificial intelligence (AI)–based automatic measurement for the M1-M2 intermetatarsal angle (IMA) in hallux valgus (HV). We hypothesized that automatic and manual measurements would have a strong correlation, and that the AI software would yield better reproducibility and would be faster compared with manual measurements.Methods:This was a multicenter retrospective comparative case-control study in which a total of 128 feet were included from 93 patients who underwent WBCT scans as part of their routine follow-up: 59 feet with symptomatic HV and 69 controls. The IMA was measured automatically using the AI software and manually on digitally reconstructed radiographs (DRRs). The AI software produced both an automatic 2D (auto 2D) and 3D (auto 3D) measurement.Results:There were strong intermethod correlations between the DRR IMA and the auto 2D (HV, r = 0.61; control, r = 0.60; all P < .0001) and auto 3D (HV, r = 0.63; control, r = 0.52; all P < .0001) measurements, respectively. The intrasoftware reproducibility was very close to 100%. Measurements took 23.6 ± 2.31 seconds and 14.5 ± 1.18 seconds, respectively, when taken manually on DRRs and automatically. Controls demonstrated a mean DRR IMA of 8.6 (95% CI, 8.1-9.1), mean auto 2D of 11.2 (95% CI, 10.7-11.7), and mean auto 3D IMA of 11.0 (95% CI, 10.5-11.5). The HV group demonstrated significantly increased IMA compared with controls (P < .0001), with a mean DRR IMA of 15.4 (95% CI, 14.8-16.1), mean auto 2D of 17.8 (95% CI, 17.2-18.4), and mean auto 3D IMA of 16.8 (95% CI, 16.8-17.4).Conclusion:Measurements generated by the WBCT AI-based automatic measurement system for IMA demonstrated strong correlations with manual measurements, with near-perfect reproducibility. Further developments are warranted in order to make this tool more usable in daily practice, particularly with respect to its use in the presence of hardware in the foot.Level of Evidence:Level III, retrospective comparative study.
      Citation: Foot & Ankle International
      PubDate: 2021-06-05T06:13:53Z
      DOI: 10.1177/10711007211015177
       
  • Four-Dimensional CT Analysis of Normal Syndesmotic Motion

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      Authors: Murray T. Wong, Charmaine Wiens, Jeremy Lamothe, W. Brent Edwards, Prism S. Schneider
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:The syndesmosis ligament complex stabilizes the distal tibiofibular joint while allowing for small amounts of physiologic motion. When injured, malreduction of the syndesmosis is the most important factor that contributes to inferior functional outcomes. Syndesmotic reduction is a dynamic measure, which is not adequately captured by conventional computed tomography (CT). Four-dimensional CT (4DCT) can image joints as they move through range of motion (ROM). The aim of this study was to employ 4DCT to determine in vivo syndesmotic motion with ankle ROM in uninjured ankles.Methods:Uninjured ankles were analyzed in patients who had contralateral syndesmotic injuries, as well as a cohort of healthy volunteers with bilateral uninjured ankles. Bilateral ankle 4DCT scans were performed as participants moved their ankles between maximal dorsiflexion and plantarflexion. Multiple measures of syndesmotic width, as well as sagittal translation and fibular rotation, were automatically extracted from 4DCT using a custom program to determine the change in syndesmotic position with ankle ROM.Results:Fifty-eight ankles were analyzed. Measures of syndesmotic width decreased by 0.7 to 1.1 mm as the ankle moved from dorsiflexion to plantarflexion (P < .001 for each measure). The fibula externally rotated by 1.2 degrees with ankle ROM (P < .001), but there was no significant motion in the sagittal plane (P = .43). No participants with bilateral uninjured ankles had a side-to-side difference in syndesmotic width of 2 mm or greater.Conclusion:4DCT allows accurate, in vivo syndesmotic measurements, which change with ankle ROM, confirming prior work that was limited to biomechanical studies. Side-to-side syndesmotic measurements are consistent within subjects, validating the method of templating syndesmotic reduction off the contralateral ankle, in a consistent ankle position, to achieve anatomic reduction of syndesmotic injury.Level of Evidence:Level II.
      Citation: Foot & Ankle International
      PubDate: 2021-06-05T06:13:42Z
      DOI: 10.1177/10711007211015204
       
  • Modified Lapidus Versus Scarf Osteotomy Outcomes for Treatment of Hallux
           Valgus Deformity

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      Authors: Megan E. Reilly, Matthew S. Conti, Jonathan Day, Aoife MacMahon, Bopha Chrea, Kristin C. Caolo, Nicholas Williams, Mark C. Drakos, Scott J. Ellis
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:The Lapidus procedure and scarf osteotomy are indicated for the operative treatment of hallux valgus; however, no prior studies have compared outcomes between the procedures. The aim of this study was to compare clinical and radiographic outcomes between patients with symptomatic hallux valgus treated with the modified Lapidus procedure versus scarf osteotomy.Methods:This retrospective cohort study included patients treated by 1 of 7 fellowship-trained foot and ankle surgeons. Inclusion criteria were age older than 18 years, primary modified Lapidus procedure or scarf osteotomy for hallux valgus, minimum 1-year postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores, and minimum 3-month postoperative radiographs. Revision cases were excluded. Clinical outcomes were assessed using 6 PROMIS domains. Pre- and postoperative radiographic parameters were measured on anteroposterior (AP) and lateral weightbearing radiographs. Statistical analysis utilized targeted minimum-loss estimation (TMLE) to control for confounders.Results:A total of 136 patients (73 Lapidus, 63 scarf) with an average of 17.8 months of follow-up were included in this study. There was significant improvement in PROMIS physical function scores in the modified Lapidus (mean change, 5.25; P < .01) and scarf osteotomy (mean change, 5.50; P < .01) cohorts, with no significant differences between the 2 groups (P = .85). After controlling for bunion severity, the probability of having a normal postoperative intermetatarsal angle (IMA;
      Citation: Foot & Ankle International
      PubDate: 2021-06-04T11:14:16Z
      DOI: 10.1177/10711007211013776
       
  • The Assessment of First Metatarsal Rotation in the Normal Adult Population
           Using Weightbearing Computed Tomography

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      Authors: Ali-Asgar Najefi, Amit Zaveri, Mohammad Khalid Alsafi, Karan Malhotra, Shelain Patel, Nicholas Cullen, Matthew Welck
      First page: 1223
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:The importance of the rotational profile of the first metatarsal is increasingly recognized in the surgical planning of hallux valgus. However, rotation in the normal population has only been measured in small series. We aimed to identify the normal range of first metatarsal rotation in a large series using weightbearing computed tomography (WBCT).Methods:WBCT scans were retrospectively analyzed for 182 normal feet (91 patients). Hallux valgus angle, intermetatarsal angle, anteroposterior/lateral talus–first metatarsal angle, calcaneal pitch, and hindfoot alignment angle were measured using digitally reconstructed radiographs. Patients with abnormal values for any of these measures and those with concomitant pathology, previous surgery, or hallux rigidus were excluded. Final assessment was performed on 126 feet. Metatarsal pronation (MPA) and α angles were measured on standardized coronal computed tomography slices. Pronation was recorded as positive. Intraobserver and interobserver reliability were assessed using intraclass correlation coefficients (ICCs).Results:Mean MPA was 5.5 ± 5.1 (range, –6 to 25) degrees, and mean α angle was 6.9 ± 5.5 (range, –5 to 22) degrees. When considering the normal range as within 2 standard deviations of the mean, the normal range identified was −5 to 16 degrees for MPA and −4 to 18 degrees for α angle. Interobserver and intraobserver reliability were excellent for both MPA (ICC = 0.80 and 0.97, respectively) and α angle (ICC = 0.83 and 0.95, respectively). There was a moderate positive correlation between MPA and α angle (Pearson coefficient 0.68, P < .001).Conclusion:Metatarsal rotation is variable in normal feet. Normal MPA can be defined as less than 16 degrees, and normal α angle can be defined as less than 18 degrees. Both MPA and α angle are reproducible methods for assessing rotation. Further work is needed to evaluate these angles in patients with deformity and to determine their significance when planning surgical correction of hallux valgus.Level of Evidence:Level III, retrospective comparative study.
      Citation: Foot & Ankle International
      PubDate: 2021-06-14T06:26:33Z
      DOI: 10.1177/10711007211015187
       
  • Percutaneous Chevron and Akin (PECA) Osteotomies for Severe Hallux Valgus
           Deformity With Mean 3-Year Follow-up

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      Authors: Thomas L. Lewis, Robbie Ray, Peter Robinson, Paul M. C. Dearden, Thomas J. Goff, Clare Watt, Peter Lam
      First page: 1231
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:Patients with severe hallux valgus deformity present technical and operative challenges with high rates of recurrence and residual deformity. The clinical and radiologic outcomes of percutaneous surgery for severe hallux valgus are not known.Methods:A retrospective review of consecutive patients with a hallux valgus angle (HVA)>40 degrees or intermetatarsal angle (IMA)>20 degrees who underwent third-generation percutaneous chevron and Akin osteotomy (PECA) for hallux valgus deformity correction.Results:Between December 2012 and August 2019, 59 feet in 50 patients underwent PECA. Preoperative and follow-up radiographic data were available for 53 feet (89.8%). Postoperative clinical patient-reported outcome measures and satisfaction results were available for 51 feet (86.4%). The mean clinical and radiographic follow-up was 3.1 years and the mean postoperative Manchester-Oxford Foot Questionnaire Index score was 15.1. There was a statistically significant improvement (P < .001) in both IMA and HVA following surgery (IMA 17.5-5.1 degrees; HVA 44.1-11.5 degrees). All patients reported they were satisfied with their outcome, with 76.8% reporting they were highly satisfied. The hallux valgus recurrence rate was 7.5%.Conclusion:Percutaneous surgery for severe hallux valgus deformity can achieve a large deformity correction, patient satisfaction, and quality of life, with reasonable rates of residual deformity and low rates of recurrence.Level of Evidence:IV
      Citation: Foot & Ankle International
      PubDate: 2021-06-11T07:30:37Z
      DOI: 10.1177/10711007211008498
       
  • The Agility Total Ankle Arthroplasty: A Concise Follow-up at a Minimum of
           20 Years

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      Authors: Nicholas Bedard, Charles L. Saltzman, Taylor Den Hartog, Samuel Carlson, John Callaghan, Greg Alvine, Frank Alvine
      First page: 1241
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:Between 1984 and 1994, a single surgeon performed 132 primary cementless total ankle replacements using the Agility total arthroplasty system. The purpose of this study was to report on the 20-year follow-up, which we believe is the first study with this length of follow-up.Methods:Living patients were contacted and interviewed to determine the status of their implant (revised or unrevised) and to answer a simple questionnaire concerning overall satisfaction, pain, and functional improvement, as in a previous study. Thirty-three (26.2%) patients with 33 (25%) ankles of the original series were alive at a minimum of 20 years postoperatively, with a median follow-up of 22 years. They were asked to return to the office for standing anteroposterior and lateral ankle and foot radiographs or to send these radiographs if performed elsewhere. Radiographs were evaluated for radiolucencies around the components and subsidence (talar component) or migration (tibial component) of components.Results:Seventeen (13.5%) ankles of the 126 available for follow-up, including 5 (15.2%) ankles in living patients, had undergone revision (n = 10) or arthrodesis (n = 7) for loosening. One additional ankle was revised for infection and 1 for talar component malposition; thus, 19 (15.1%) ankles were revised.Conclusion:These results should provide a 20-year benchmark for newer total ankle arthroplasty designs when a similar length of follow-up becomes available.Level of Evidence:Level III, retrospective cohort study.
      Citation: Foot & Ankle International
      PubDate: 2021-05-21T10:58:15Z
      DOI: 10.1177/10711007211010179
       
  • Plafond Malreduction and Talar Dome Impaction Accelerates Arthrosis After
           Supination-Adduction Ankle Fracture

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      Authors: Michael F. Githens, Malcolm R. DeBaun, Kimberly A Jacobsen, Hunter Ross, Reza Firoozabadi, Justin Haller
      First page: 1245
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:Supination-adduction (SAD) type II ankle fractures can have medial tibial plafond and talar body impaction. Factors associated with the development of posttraumatic arthritis can be intrinsic to the injury pattern or mitigated by the surgeon. We hypothesize that plafond malreducton and talar body impaction is associated with early posttraumatic arthrosis.Methods:A retrospective cohort of skeletally mature patients with SAD ankle fractures at 2 level 1 academic trauma centers who underwent operative fixation were identified. Patients with a minimum of 1-year follow-up were included. The presence of articular impaction identified on CT scan was recorded and the quality of reduction on final intraoperative radiographs was assessed. The primary outcome was radiographic ankle arthrosis (Kellgren-Lawrence 3 or 4), and postoperative complications were documented.Results:A total of 175 SAD ankle fractures were identified during a 10-year period; 79 patients with 1-year follow-up met inclusion criteria. The majority of injuries resulted from a high-energy mechanism. Articular impaction was present in 73% of injuries, and 23% of all patients had radiographic arthrosis (Kellgren-Lawrence 3 or 4) at final follow-up. Articular malreduction, defined by either a gap or step>2 mm, was significantly associated with development of arthrosis. Early treatment failure, infection, and nonunion was rare in this series.Conclusion:Malreduction of articular impaction in SAD ankle fractures is associated with early posttraumatic arthrosis. Recognition and anatomic restoration with stable fixation of articular impaction appears to mitigate risk of posttraumatic arthrosis. Investigations correlating postoperative and long-term radiographic findings to patient-reported outcomes after operative treatment of SAD ankle fractures are warranted.Level of Evidence:Level IV, retrospective case series.
      Citation: Foot & Ankle International
      PubDate: 2021-05-21T10:53:55Z
      DOI: 10.1177/10711007211006032
       
  • A Prospective Cohort Study Comparing Functional Outcomes of Primary and
           Revision Ankle Replacements

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      Authors: Toby Jennison, Andrew King, Christopher Hutton, Ian Sharpe
      First page: 1254
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:The number of ankle and revision ankle replacements performed is increasing. There is limited research into functional outcomes, especially in revision ankle replacements. The primary aim of this cohort study was to determine the functional improvements following primary and revision ankle replacements and compare which gave the greatest improvement in functional scores.Methods:A single-center prospective cohort study was undertaken between 2015 and 2018. All patients were followed up for a minimum of 2 years. Patients undertook a preoperative and 2-year Manchester Oxford Foot Questionnaire (MoxFQ) score. The Mann Whitney test was undertaken.Results:A total of 33 primary and 23 revision ankle replacements were performed between 2015 and 2018. The mean age was 69.3 years for primary replacements and 64.7 years for revision replacements. All primary replacements were the Infinity ankle replacement. Revision replacements were either the Inbone II or Invision. The indication for revision was 9 aseptic loosening, 6 infections, 5 cysts, and 3 malposition. Seventeen were performed as a single stage and 6 as a 2-stage revision. The overall MoxFQ improved by a mean of 48.8 for primaries and 20.2 for revisions (P = .024). The walking/standing domain improved by 57.5 for primaries and 22.5 for revisions (P = .016), the pain score improved by 43.0 and 32.3 (P = .009), and the social interaction improved by 40.0 and 11.7 (P = .128).Conclusion:Both primary and revision ankle replacements result in improved functional scores. In this relatively small cohort with the implants used, primary ankle replacements though have a significantly greater improvement in functional scores compared to revision ankle replacements.Level of Evidence:Level II, prospective cohort study.
      Citation: Foot & Ankle International
      PubDate: 2021-06-11T07:29:56Z
      DOI: 10.1177/10711007211010188
       
  • Clinical and Radiographic Results of Ankle Joint Preservation Surgery in
           Posterior Ankle Arthritis

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      Authors: Jaeyoung Kim, Ji-Beom Kim, Woo-Chun Lee
      First page: 1260
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:Little information is available about how to manage ankles with eccentric arthritis in the sagittal plane. This study aimed to report clinical and radiographic outcomes following joint preservation surgery for ankles with eccentric arthritis at the posterior tibiotalar joint and a plantarflexed talus in the sagittal plane, which we named posterior ankle arthritis.Methods:Ten ankles with posterior ankle arthritis were treated with realignment surgery between 2017 and 2018. Posterior ankle arthritis was defined as having both (1) eccentric narrowing of the joint space at the posterior aspect of the tibiotalar joint on weightbearing lateral radiographs and (2) coronal talar tilt angle less than 4 degrees on weightbearing anteroposterior radiographs. Flatfoot reconstruction with a hindfoot arthrodesis procedure was performed in all patients (subtalar arthrodesis, n = 9; triple arthrodesis, n = 1), and a supramalleolar osteotomy was added in patients with varus distal tibial alignment (n = 6). Pain, functional outcome (foot function index [FFI]), radiographic arthritis stage (stage I to IV), and 9 radiographic parameters, including lateral talar center migration (LTCM), were evaluated on pre- and postoperative weightbearing radiographs. All patients completed a minimum 2-year follow-up.Results:Preoperative radiographic evaluation demonstrated that ankles with posterior arthritis had a lower medial longitudinal arch, forefoot abduction, and valgus hindfoot alignment. Postoperatively, sagittal tibiotalar alignment was restored, as evidenced by an improved median LTCM from −3.3 to −0.3 mm (P < .001). The radiographic arthritis stage improved in 7 (70%) patients, whereas 3 (30%) remain unchanged in the same stage. The median score for pain (visual analog scale) decreased significantly from 8 to 2, and the median FFI improved significantly from 67.8 to 23.4 (P < .001). None of the patients underwent conversion to joint-sacrificing procedures at the latest follow-up.Conclusion:The study results suggest a possible relationship between posterior ankle arthritis and the plantarflexion of the talus, which can be seen in the setting of a flatfoot deformity. Reconstruction of the flatfoot deformity using subtalar arthrodesis restored the tibiotalar relationship in the sagittal plane and resulted in clinical improvements at an average 2.3-year follow-up in this 10-ankle case series.Level of Evidence:Level IV, case series.
      Citation: Foot & Ankle International
      PubDate: 2021-06-07T04:44:59Z
      DOI: 10.1177/10711007211011182
       
  • Changes in the Syndesmotic Reduction After Syndesmotic Suture-Button
           Fixation for Ankle Malleolar Fractures: 1-Year Longitudinal Evaluations
           Using Computed Tomography

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      Authors: Seiji Kimura, Satoshi Yamaguchi, Yoshimasa Ono, Shotaro Watanabe, Ryuichiro Akagi, Takahisa Sasho, Seiji Ohtori
      First page: 1270
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:Evaluation over time is important in assessing the reduction of the syndesmosis after suture-button fixation for ankle malleolar fractures. The purposes of this study were to evaluate time-dependent change in the syndesmotic reduction immediately after suture-button fixation for ankle malleolus fractures and 1 year after surgery using computed tomography, and to investigate the reliability of the measurement values to evaluate the reduction of syndesmosis.Methods:We assessed 28 patients who underwent suture-button fixation for ankle fractures. Syndesmotic reduction was assessed within 2 weeks of the fracture surgery and 1 year after surgery using axial computer tomographic images. Side-to-side differences in the anterior, central, and posterior tibiofibular distances, anteroposterior fibular translation, fibular rotation, and syndesmosis area were measured.Results:The mean anterior tibiofibular distance and anteroposterior fibular translation were 1.8 mm and 1.5 mm, respectively, after syndesmotic fixation. They decreased to 1.2 mm and 0.6 mm, respectively, at 1 year after surgery (P = .03 and P = .01, respectively). The other measurement values did not change over time. The minimum detectable change in the distance of measurements was 1 mm or less.Conclusion:The anterior tibiofibular distance and anteroposterior fibular translation had decreased 1 year after fixation in ankle malleolar fractures with syndesmotic suture button. Even if the fibula is posteriorly malreduced by the time computed tomography is performed immediately after surgery, the fibula may return to a good position 1 year after surgery.Level of Evidence:Level IV, case series.
      Citation: Foot & Ankle International
      PubDate: 2021-05-21T10:56:22Z
      DOI: 10.1177/10711007211008518
       
  • Physical Function and Pain Interference Levels of Hallux Rigidus Patients
           Before and After Synthetic Cartilage Implant vs Arthrodesis Surgery

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      Authors: Peter Y. Joo, Judith F. Baumhauer, Olivia Waldman, Samantha Hoffman, Jeffrey Houck, Jessica M. Kohring, A. Samuel Flemister, John P. Ketz, Benedict F. DiGiovanni, Irvin Oh
      First page: 1277
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:Hallux rigidus is a common and painful degenerative condition of the great toe limiting a patient’s physical function and quality of life. The purpose of this study was to investigate pre- and postoperative physical function (PF) and pain interference (PI) levels of patients undergoing synthetic cartilage implant hemiarthroplasty (SCI) vs arthrodesis (AD) for treatment of hallux rigidus using the Patient-Reported Outcomes Measurement Information System (PROMIS).Methods:PROMIS PF and PI t scores were analyzed for patients who underwent either SCI or AD. Postoperative final PROMIS t scores were obtained via phone survey. Linear mixed model analysis was used to assess differences in PF and PI at each follow-up point. Final follow-up scores were analyzed using independent sample t tests.Results:Total 181 (59 SCI, 122 AD) operatively managed patients were included for analysis of PROMIS scores. Final phone survey was performed at a minimum of 14 (mean 33, range, 14-59) months postoperatively, with 101 patients (40 SCI, 61 AD) successfully contacted. The mean final follow-up was significantly different for SCI and AD: 27 vs 38 months, respectively (P < .01). The mean age of the SCI cohort was lower than the AD cohort (57.5 vs 61.5 years old, P = .01). Average PF t scores were higher in the SCI cohort at baseline (47.1 and 43.9, respectively, P = .01) and at final follow-up (51.4 vs 45.9, respectively, P < .01). A main effect of superior improvement in PF was noted in the SCI group (+4.3) vs the AD group (+2) across time intervals (P < .01). PI t scores were similar between the 2 procedures across time points.Conclusion:The SCI cohort reported slightly superior PF t scores preoperatively and at most follow-up time points compared with the arthrodesis group. No differences were found for PI or complication rates between the 2 treatment groups during this study time frame.Level of Evidence:Level III.
      Citation: Foot & Ankle International
      PubDate: 2021-05-24T07:57:03Z
      DOI: 10.1177/10711007211007843
       
  • Outcomes of Percutaneous Calcaneoplasty for Insertional Achilles Tendon
           Problems

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      Authors: Stefano Ferranti, Filippo Migliorini, Federico Maria Liuni, Marco Corzani, Alfio Azzarà, Flavio Polliano, Abusaa Saher Sami Tawfiq, Nicola Maffulli
      First page: 1287
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:Percutaneous procedures have been used recently to treat insertional Achilles tendon problems. The present study reports our results of this treatment approach.Methods:Patients undergoing percutaneous calcaneoplasty for insertional Achilles tendon problems were retrieved. Patients completed the visual analog scale (VAS) for pain and the Victorian Institute of Sports Assessment–Achilles (VISA-A) questionnaire before the operative procedure and at the last follow-up. At the last follow-up, we asked the patients whether they were completely satisfied, moderately satisfied, or unsatisfied after the procedure. Complications were also recorded.Results:A total of 27 patients were enrolled. The average follow-up was 26.5 months (range 6-68). The mean age of patients was 56.2 years (24-82). The mean VAS score before surgery was 8.1 ± 0.9 decreasing by the last follow-up to 2.4 ± 2.3 (P < .0001). The mean VISA-A score improved from 20.7 ± 5.4 to 75.7 ± 25.5 at last follow-up, an improvement of 55% (P < .0001). At the last follow-up, 84.5% (22 of 27) patients were completely satisfied with the procedure, 7.4% (2 of 27) moderately satisfied, and 11.1% (3 of 27) were not satisfied. These last 3 patients presented recurrence of symptoms, requiring revision surgery.Conclusion:For the selected patients, we found percutaneous calcaneoplasty to be an effective treatment for insertional Achilles tendon problemsLevel of Evidence:Level III, retrospective study.
      Citation: Foot & Ankle International
      PubDate: 2021-06-12T06:48:58Z
      DOI: 10.1177/10711007211004963
       
  • The Impact of Coronal Plane Deformity on Ankle Arthrodesis and
           Arthroplasty

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      Authors: Michael D. Johnson, Jane B. Shofer, Sigvard T. Hansen, William R. Ledoux, Bruce J. Sangeorzan
      First page: 1294
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:Ankle coronal plane deformity represents a complex 3-dimensional problem, and comparative data are lacking to guide treatment recommendations for optimal treatment of end-stage ankle arthritis with concomitant coronal plane deformity.Methods:In total, 224 patients treated for end-stage ankle arthritis were enrolled in an observational trial. Of 112 patients followed more than 2 years, 48 patients (19 arthrodesis, 29 arthroplasty) had coronal plane deformity and were compared to 64 patients without coronal plane deformity (18 arthrodesis, 46 arthroplasty) defined as greater than 10 degrees of varus or valgus. The arthroplasty implants used had different internal constraints to intracomponent coronal plane tilting. Patients completed Musculoskeletal Functional Assessment (MFA) and SF-36 preoperatively and at 3, 6, 12, 24, and 36 months postoperatively. Measures included change in SF-36 and MFA, as well as compared reoperation rates and pain scales.Results:For the groups with coronal plane ankle deformity, the median for the arthrodesis group was 19.0 degrees and the median for the arthroplasty group was 16.9 degrees. In the deformity cohort during the follow-up period, we had 7 major reoperations: 2 in the arthrodesis group and 5 in the arthroplasty group, all with the less constrained implant design. MFA, vitality, and social function of the SF-36 improved for all groups. Patients without preoperative deformities had greater improvement with fusion or replacement at both 2 and 3 years. There was no difference in improvement between those patients with coronal deformity who received arthroplasty vs arthrodesis.Conclusion:Patients with and without coronal plane deformity may benefit from ankle arthroplasty and arthrodesis, although greater improvements may be expected in those without preoperative deformity. In this study, at final follow-up of 3 years, overall we found no meaningful difference in patient-reported outcomes between the patients with preoperative coronal plane deformities whether they had a fusion or a replacement as treatment for end-stage ankle arthritis.Level of Evidence:II, comparative study.
      Citation: Foot & Ankle International
      PubDate: 2021-06-10T10:42:35Z
      DOI: 10.1177/10711007211015185
       
  • Impact of the Subtle Lisfranc Injury on Foot Structure and Function

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      Authors: Daniel Garríguez-Pérez, María Puerto-Vázquez, José Luis Tomé Delgado, Enrique Galeote, Fernando Marco
      First page: 1303
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:The subtle Lisfranc injury is the disruption of the osteoligamentary complex between the first cuneiform and the second metatarsal, resulting in minor widening of this space that is often difficult to detect with plain radiographs. In this study, we assessed the results after treatment of the different stages of subtle Lisfranc injuries, focusing on their impact on foot arch anatomy and functionality at short- to midterm follow-up.Methods:A retrospective study including patients treated in our center for a subtle Lisfranc injury between 2012 and 2019 was conducted. Demographic, epidemiologic, radiographic, and clinical data were obtained and assessed, focusing on foot arch structure and foot function, which was evaluated with the American Orthopaedic Foot & Ankle Society (AOFAS) midfoot score and the Foot Function Index (FFI).Results:A total of 42 patients with a mean age of 49 ± 17.5 years were included, with an average of 4.3 years’ follow-up (range, 1-8). Stage I injuries according to Nunley classification represented 19% and were treated conservatively. Stage II (66.7%) and stage III (14.3%) injuries were treated operatively, via osteosynthesis with screws (74%), K-wires (19%), or plates (7%). Flattening of foot arch after treatment was observed in 42.9% of patients, with significant increases in Costa-Bertani (12 ± 7 degrees), Hibbs (7 ± 6 degrees), and Meary (3 ± 1 degrees) angles. Other complications included complex regional pain syndrome (28.6%) and painful hardware (23.8%). Secondary joint arthrodesis was needed in 16.6% of patients. Chronic pain was present in 71.4% of patients with a mean visual analog scale (VAS) pain score at final follow-up of 4 of 10 points. Results in AOFAS midfoot score and FFI were 87.4 ± 8.3 and 15 ± 6.4, respectively.Conclusion:The subtle Lisfranc injury shows dissociation between the initial relatively mild radiographic changes and important future complications. Chronic pain and foot arch flattening were not uncommon. Overall foot function in the short- or midterm was found to be modestly diminished in this somewhat heterogenous cohort.Level of Evidence:Level IV, therapeutic case series.
      Citation: Foot & Ankle International
      PubDate: 2021-06-10T10:41:23Z
      DOI: 10.1177/10711007211012956
       
  • Sex-Specific Differences Following Lateral Ankle Ligament Repair

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      Authors: Ezra Goodrich, Matthew L. Vopat, Jordan Baker, Armin Tarakemeh, Kimberly Templeton, Mary K. Mulcahey, J. Paul Schroeppel, Scott Mullen, Bryan G. Vopat
      First page: 1311
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:Chronic ankle instability is a common condition that can be treated with lateral ankle ligament repair. These procedures have a reported success rate greater than 85% in the literature, but little has been reported about the differences in postoperative outcomes between males and females. The purpose of this study was to evaluate sex-specific outcomes following lateral ankle ligament repair.Methods:In this systematic review and meta-analysis, we used Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria to search for articles on electronic databases and included studies in which study participants underwent primary lateral ligament repair and sex-specific outcomes were evaluated. Functional postoperative outcomes for males and females were recorded and statistically analyzed.Results:Out of 2768 studies, 7 (0.25%) met inclusion criteria and were analyzed in this review. These studies included 618 patients (402 males [65%] and 216 females [35%]) who underwent primary lateral ligament repair for ankle instability. Karlsson score (P = .1582) and American Orthopaedic Foot & Ankle Society (AOFAS) score (P = .1586) analyses found no statistically significant difference between males and females. Postoperative success rate—defined as a “good” or “excellent” Karlsson score (>81)—was not found to be significantly different between males and females (P = .9374).Conclusion:There was no difference in postoperative mean Karlsson scores, AOFAS scores, or success rates between males and females who underwent primary lateral ankle ligament repair.Level of Evidence:Level IV, therapeutic.
      Citation: Foot & Ankle International
      PubDate: 2021-05-22T12:38:01Z
      DOI: 10.1177/10711007211004191
       
  • Trends in the Utilization of Ankle Replacements: Data From Worldwide
           National Joint Registries

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      Authors: Thomas A. Perry, Alan Silman, David Culliford, Lucy Gates, Nigel Arden, Catherine Bowen
      First page: 1319
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:Over the past decade, there has been a growth in the use of ankle replacements. Data from national joint registries have shown between-country differences in the utilization of ankle replacement. The reasons for these differences are, however, not well understood. Our aims were to describe and compare the annual incidence of primary ankle replacement between countries and, to examine potential reasons for variation over time.Methods:We used aggregate data and summary statistics on ankle replacements for the period 1993 to 2019 from national joint replacement registries in Australia, Finland, New Zealand, Norway, Sweden and the United Kingdom. From the annual recorded counts of procedures, demographic data were extracted on age, sex distribution, and indication(s) for primary ankle replacement. Registry-level summary results were also obtained on data completeness, counts of hospitals/units, and health care providers performing ankle replacements annually and data collection processes (mandatory vs voluntary). Annual ankle replacement incidence for all diagnoses and, by indication categories (osteoarthritis [OA] and rheumatoid arthritis [RA]), were calculated per 100 000 residential population aged ≥18 years.Results:For the period with data from all 6 countries (2010-2015), New Zealand had the largest annual incidence (mean ± SD) of 3.3 ± 0.2 ankle replacement procedures per 100 000 population whereas Finland had the lowest incidence (0.92 replacements). There were no common temporal trends in the utilization of ankle replacements. Over the years studied, OA was the predominant diagnosis in the United Kingdom, Australia, and New Zealand, whereas RA was the most common indication in Scandinavia.Conclusions:In these 6 countries, we found marked differences in the utilization of ankle replacements. Registry-related factors including data completeness and the number of hospitals/surgeons performing ankle replacements are likely to contribute to the observed between-country differences and need to be carefully considered when interpreting comparisons for this less common site for joint replacement surgery.Level of Evidence:Level III, retrospective study.
      Citation: Foot & Ankle International
      PubDate: 2021-06-17T10:33:46Z
      DOI: 10.1177/10711007211012947
       
  • Accessibility and Thickness of Medial and Lateral Talar Body Cartilage for
           Treatment of Ankle and Foot Osteochondral Lesions

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      Authors: Erik Nott, Lauren M. Matheny, Thomas O. Clanton, Carly Lockard, Brenton W. Douglass, Kira K. Tanghe, Nicholas Matta, Alex W. Brady
      First page: 1330
      Abstract: Foot & Ankle International, Ahead of Print.
      Background:The purposes of this study were to determine (1) if cartilage thicknesses on the talar dome and medial/lateral surfaces of the talus were similar, (2) whether there was sufficient donor cartilage surface area on the medial and lateral talar surfaces to repair talar dome cartilage injuries of the talus, and (3) whether the cartilage surface could be increased following anterior talofibular ligament (ATFL) and sectioning of the tibionavicular and tibiospring portion of the anterior deltoid.Methods:Medial and lateral approaches were utilized in 8 cadaveric ankles to identify the accessible medial, lateral, and talar dome cartilage surfaces in 3 conditions: (1) intact, (2) ATFL release, and (3) superficial anterior deltoid ligament release. The talus was explanted, and the cartilage areas were digitized with a coordinate measuring machine. Cartilage thickness was quantified using a laser scanner.Results:The mean cartilage thickness was 1.0 ± 0.1 mm in all areas tested. In intact ankles, the medial side of the talus showed a larger total area of available cartilage than the lateral side (152 mm2 vs 133 mm2). ATFL release increased the available cartilage area on the medial and lateral sides to 167 mm2 and 194 mm2, respectively. However, only the lateral talar surface had sufficient circular graft donor cartilage available for autologous osteochondral transplantation (AOT) procedures of the talus. After ATFL and deltoid sectioning, there was an increase in available graft donor cartilage available for AOT procedures.Conclusion:The thickness of the medial and lateral talar cartilage surfaces is very similar to that of the talar dome cartilage surface, which provides evidence that the medial and lateral surfaces may serve as acceptable AOT donor cartilage. The surface area available for AOT donor site grafting was sufficient in the intact state; however, sectioning the ATFL and superficial anterior deltoid ligament increased the overall lateral talar surface area available for circular grafting for an AOT procedure that requires a larger graft. These results support the idea that lateral surfaces of the talus may be used as donor cartilage for an AOT procedure since donor and recipient sites are similar in cartilage thickness, and there is sufficient cartilage surface area available for common lesion sizes in the foot and ankle.Clinical Relevance:This anatomical study investigates the feasibility of talar osteochondral autografts from the medial or lateral talar surfaces exposed with standard approaches. It confirms the similar cartilage thickness of the talar dome and the ability to access up to an 8- to 10-mm donor graft from the lateral side of the talus after ligament release. This knowledge may allow better operative planning for use of these surfaces for osteochondral lesions within the foot and ankle, particularly in certain circumstances of a revision microfracture.
      Citation: Foot & Ankle International
      PubDate: 2021-05-29T06:57:36Z
      DOI: 10.1177/10711007211015189
       
  • Rotational Osteotomy and Subtalar Arthrodesis for Subtalar Arthritis With
           Calcaneal Malunion: A Technical Note

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      Authors: Hyong Nyun Kim, Young Uk Park, Bom Soo Kim, Mark E. Easley
      First page: 1340
      Abstract: Foot & Ankle International, Ahead of Print.

      Citation: Foot & Ankle International
      PubDate: 2021-05-22T12:44:42Z
      DOI: 10.1177/10711007211008512
       
  • Evaluating and Managing the Painful Total Ankle Replacement

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      Authors: Jensen K. Henry, Carson Rider, Elizabeth Cody, Scott J. Ellis, Constantine Demetracopoulos
      First page: 1347
      Abstract: Foot & Ankle International, Ahead of Print.
      The number of total ankle replacements (TARs) performed in the United States has dramatically increased in the past 2 decades due to improvements in implant design and surgical technique. Yet as the prevalence of TAR increases, so does the likelihood of encountering complications and the need for further surgery. Patients with new-onset or persistent pain after TAR should be approached systematically to identify the cause: infection, fracture, loosening/subsidence, cysts/osteolysis, impingement, and nerve injury. The alignment of the foot and ankle must also be reassessed, as malalignment or adjacent joint pathology can contribute to pain and failure of the implant. Novel advanced imaging techniques, including single-photon emission computed tomography and metal-subtraction magnetic resonance imaging, are useful and accurate in identifying pathology. After the foot and ankle have been evaluated, surgeons can also consider contributing factors such as pathology outside the foot/ankle (eg, in the knee or the spine). Treatment of the painful TAR is dependent on etiology and may include debridement, bone grafting, open reduction and internal fixation, realignment of the foot, revision of the implants, arthrodesis, nerve repair/reconstruction/transplantation surgery, or, in rare cases, below-knee amputation.Level of Evidence: Level V, expert opinion or review.
      Citation: Foot & Ankle International
      PubDate: 2021-07-28T06:26:18Z
      DOI: 10.1177/10711007211027273
       
  • The Importance of Increasing Awareness of FootCareMD

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      Authors: Sudheer C. Reddy, David A. Porter
      First page: 1362
      Abstract: Foot & Ankle International, Ahead of Print.

      Citation: Foot & Ankle International
      PubDate: 2021-07-03T12:47:29Z
      DOI: 10.1177/10711007211027275
       
 
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