Foot & Ankle Orthopaedics最新文献

Background: Ankle fractures are common orthopaedic injuries, and their management is primarily determined by fracture stability. The Lauge-Hansen classification system categorizes fractures according to mechanism of injury and ligaments involved. Supination external rotation (SER) type 2 fractures correspond to stable weber B fractures and are traditionally treated nonoperatively, whereas SER 3 and SER 4 fractures, characterized by syndesmosis disruption, typically require surgical intervention. We hypothesize that some apparently stable injuries may involve additional structures, challenging the conventional treatment approach. This study aims to determine the prevalence of SER 3 and SER 4 ankle injuries among radiographically stable SER 2 fractures.

Method: The study used baseline data from a longitudinal cohort conducted at Gold Coast Hospital and Health Service (GCHHS). Patients attending the GCHHS fracture clinic with radiographically stable SER 2 fractures were invited to participate. Those meeting the eligibility criteria underwent ankle magnetic resonance imaging (MRI) to evaluate the integrity of syndesmotic and ankle ligaments.

Results: Fifty-six participants were recruited, 38 (68%) female and 18 (32%) male, with a mean age of 47.2 years. All had stable syndesmoses on radiographic assessment and diagnosed with stable SER 2 ankle fractures. MRI scans revealed that 71% (n = 40) met the criteria for SER 2 injuries, 25% (n = 14) for SER 3 injuries with complete ruptures of posterior inferior tibiofibular ligament (PITFL), and 4% (n = 2) for SER 4 injuries with PITFL and deltoid ligament (DL) ruptures. These results challenge the assumption that radiographically stable SER 2 fractures are consistently stable in terms of additional structures involved.

Conclusion: The study highlights that a considerable proportion of seemingly stable ankle fractures involve more structures than previously thought. This suggests the management of SER 3 and SER 4 injuries could include nonoperative treatment.

Level of evidence: Level III, cohort study.

Background: A modern technique for the treatment of hallux rigidus (HR) is first metatarsophalangeal (MTP) hemiarthroplasty with the use of a Cartiva synthetic cartilage implant. Current scientific literature reporting early outcomes of the procedure is sparse and mixed, indicating the need for further analysis. The objective of this study was to compare improvement in visual analog scale (VAS) scores with first MTP hemiarthroplasty with Cartiva implant (HI), allograft interposition arthroplasty (IA), and arthrodesis (A) in patients who failed conservative management or cheilectomy.

Methods: A retrospective cohort study of 99 patients was performed. There were 49 patients in the HI group, 25 patients in the IA group, and 25 patients in the A group. A follow-up survey was administered from which updated VAS and updated American Orthopaedic Foot & Ankle Society scores were obtained.

Results: Mean VAS scores improved by 2.73 (SD ± 2.80) points in the HI group, 4.16 (SD ± 2.01) points in the IA group, and 4.36 (SD ± 3.67) points in the A group (P = .035). Mean AOFAS scores improved by 14.90 (SD ± 17.31) points in the HI group, 27.80 (SD ± 15.22) points in the IA group, and 27.88 (SD ± 25.34) points in the A group (P = .005). There were 3 (6.1%) revision surgeries in the HI group, 2 (8.0%) revision surgeries in the A group, and no revision surgeries in the IA group (P = .59). Within the HI group, all 3 revisions were due to pain associated with the implant and were revised to MTP arthrodesis. The A group had 1 revision due to broken hardware and 1 revision due to infection. In both cases, the patients were treated with hardware removal.

Conclusion: Pain and function may be slightly more improved with interpositional arthroplasty and arthrodesis for the treatment of HR, when compared to hemiarthroplasty with the Cartiva implant.

Level of evidence: Level III, therapeutic studies; case-control study.

Background: Hindfoot arthrodesis is a procedure commonly performed to address degenerative changes and/or malalignment of the hindfoot, yet robust literature comparing traditional and modern constructs is sparse. The purpose of this study is to evaluate the efficacy of nitinol staples in hindfoot arthrodesis as compared to isolated screws and combined staple and screw constructs.

Methods: A 10-year retrospective review of all patients undergoing hindfoot arthrodesis at our institution was performed. Hindfoot arthrodesis was defined as either a triple (subtalar, talonavicular, and calcaneocuboid), double (subtalar + talonavicular), or isolated arthrodesis. Outcomes included fusion success rate and reoperation rate. A postoperative CT confirming the presence or absence of osseous bridging was required for inclusion in the fusion outcome analysis.

Results: We assessed 113 patients who underwent arthrodesis procedures across 128 joints in the hindfoot. There was no significant difference in functional outcomes between screws, staples, or the combination screw and staple constructs used in hindfoot arthrodesis. However, screws alone were associated with a significantly higher complication rate than staple-only fixation (P = .028).

Conclusion: Nitinol staples are effective in hindfoot arthrodesis with respect to fusion success rate and may be associated with decreased revision rates compared with traditional screws only or staple plus screw constructs. Larger studies will be necessary to validate these findings and contribute to an assessment of the usage of these nascent constructs in hindfoot arthrodesis.

Level of evidence: Level III, retrospective cohort study.

Background: Patient reliance on internet resources for clinical information has steadily increased. The recent widespread accessibility of artificial intelligence (AI) tools like ChatGPT has increased patient reliance on these resources while also raising concerns about the accuracy, reliability, and appropriateness of the information they provide. Previous studies have evaluated ChatGPT and found it could accurately respond to questions on common surgeries, such as total hip arthroplasty, but is untested for uncommon procedures like total ankle arthroplasty (TAA). This study evaluates ChatGPT-4's performance in answering patient questions on TAA and further explores the opportunity for physician involvement in guiding the implementation of this technology.

Methods: Twelve commonly asked patient questions regarding TAA were collated from established sources and posed to ChatGPT-4 without additional input. Four fellowship-trained surgeons independently rated the responses using a 1-4 scale, assessing accuracy and need for clarification. Interrater reliability, divergence, and trends in response content were analyzed to evaluate consistency across responses.

Results: The mean score across all responses was 1.8, indicating an overall satisfactory performance by ChatGPT-4. Ratings were consistently good on factual questions, such as infection risk and success rates, whereas questions requiring nuanced information, such as postoperative protocols and prognosis, received poorer ratings. Significant variability was observed among surgeons' ratings and between questions, reflecting differences in interpretation and expectations.

Conclusion: ChatGPT-4 demonstrates its potential to reliably provide discrete information for uncommon procedures such as TAA, but it lacks the capability to effectively respond to questions requiring patient- or surgeon-specific insight. This limitation, paired with the growing reliance on AI, highlights the need for AI tools tailored to specific clinical practices to enhance accuracy and relevance in patient education.

Background: The treatment of chronic ankle sprains has largely focused on lateral ankle instability in the literature. There is a scarcity of data regarding the diagnosis and management of chronic medial ankle instability secondary to deltoid ligament injury.

Methods: A literature search was performed using the National Center for Biotechnology Information (NCBI) database for studies evaluating chronic ankle instability (CAI) involving deltoid ligament pathology. Studies were evaluated for workup including clinical presentation, imaging, treatment algorithm and operative techniques. Descriptive statistical analysis was conducted across the pooled data set.

Results: Nine studies representing 516 patients with CAI were included in our analysis. Plain radiographs assessed talar-tilt angle in 440 patients (85%) and anterior displacement in 296 patients (57%). A total of 465 patients underwent magnetic resonance imaging, with deltoid injuries identified in 289 (62%) of patients. Of these 289 patients, superficial deltoid involvement was specified in 61 patients and deep deltoid in 146 patients. Surgical treatment most commonly included arthroscopy in 255 patients with open deltoid ligament repair in 199 patients. Repair method included suture anchors in 173 patients (87%), bone tunnels in 23 patients (12%), and unspecified technique in 3 patients (1.5%). Thirteen patients (6.5%) had suture anchor repairs augmented with an internal brace. Three patients underwent deltoid reconstruction with plantaris tendon autograft.

Conclusion: Deltoid ligament injuries are common in patients with CAI. These data improve our understanding of chronic deltoid injuries and can help patients and surgeons better comprehend the pathoanatomy of chronic ankle instability.

Level of evidence: Level III, retrospective cohort study.

Background: Achilles tendon rupture (ATR) is a common injury with an estimated incidence of about 7 to 40 per 100,000 person-years. Identifying risk factors for ATR is an important step toward injury prevention. Modifiable factors, such as body mass index (BMI), are of particular interest because of the potential for intervention, and recent studies have shown mixed results for BMI as a risk factor for ATR. This case-control study aims to compare the BMI of patients diagnosed with a primary ATR to age and sex-matched controls diagnosed with an ankle sprain.

Methods: A retrospective chart review of 168 patients was performed, which included 56 patients with ATR age- and sex-matched with 112 ankle sprain controls. Demographics and BMI data were collected and compared across the 2 groups. Mann-Whitney U tests and Fisher exact tests were used to determine differences between groups. Multivariate logistic regression models were used to further analyze significant variables.

Results: The mean BMI for ATR was 33.4 and ankle sprain was 31.9, which was not statistically significant (P = .162). When BMI was divided into subclasses, there were significantly fewer patients who sustained ATR compared to ankle sprain controls in the class 1 (BMI 18-25; P = .020). Participating in sports (P < .001) and African American race (P < .001) were the only other statistically significant risk factors. Multivariate logistic regression showed increased likelihood of ATR for patients who were African American (P = .006), participated in athletics (P < .001), and had a BMI higher than 25 (P = .018).

Conclusion: This study found that a BMI between 18 and 25 was associated with lower rates of ATR when compared to BMI classes greater than 25. Our data suggests that BMI may be an independent factor associated with ATR, even in patients engaging in sporting activity.

Level of evidence: Level III, case-control study.

Background: Over the past 2 decades, various initiatives have aimed to enhance diversity in orthopaedic surgery, promoting greater racial, ethnic, and gender equity. Building on this progress, demographic data on orthopaedic fellowship matches has been collected over the last 3 years. This study seeks to analyze trends in applicants to foot and ankle fellowships, characterize the applicant pool, and identify traits associated with successful matches.

Methods: All applicant information from a fellowship application service site was obtained for match years 2022-2024. Applicants were selected only if they applied to the specific subspecialty fellowship. Gender, race, and ethnicity were recorded. Applicant factors such as Alpha Omega Alpha (AOA) status, Gold Humanitarian status, United States Medical Licensing Examination (USMLE) Step 2 score, number of applications, and number of interview invitations were used. Applicant medical school status, including allopathic, osteopathic, Canadian, and foreign medical graduate (FMG) were analyzed. χ² test was performed between US and FMG applicants. Univariate and multivariate binomial logistic regression was performed for FMGs.

Results: There were 286 applicants, 82.8% males, 16.5% females, 133 US- and Canadian-trained graduates, and 153 FMGs. The match rate for US- and Canadian-trained graduates was 99.2% compared with FMGs, which was 43.7% and associated with lower matching rates (P < .00001). When performing analysis in US and FMG groups independently because of multicollinearity, no factors could be associated with matching. Only when the applicant had FMG status, then the number of interview invitations were associated with matching. When the number of interviews approached 6, the likelihood of matching was >95%.All except 1 US F&A applicant matched into an F&A fellowship. During the match period, US-trained applicants were 28%-32% female, 4%-8% Black/African American, 8%-17% Asian, 65%-73% White, 2%-4% American Indian, and 2%-8% Hispanic, with no Native Hawaiian and Pacific Islanders applying. Female applicants were above representation compared to Accreditation Council for Graduate Medical Education (ACGME) numbers, but the remaining race and ethnicity applicants were within the range of current ACGME standings, which is still lower than US Census results.

Conclusion: Nearly all US-trained foot and ankle applicants matched, whereas FMG applicants matched 43% of the time.

Background: Orthopaedic patients' expectations for surgical treatment are often disparate compared with those of their surgeon. There is increasing interest in assessing and understanding patient preoperative expectations and their potential association with postoperative satisfaction. Previous literature has found several predictors of patient-provider discrepancies in expectations for elective orthopaedic surgery, although no studies have included patients undergoing surgery for traumatic injuries. The aim of this study was to determine if there are differences in expectations between patients undergoing elective vs nonelective foot and ankle surgeries.

Methods: A prospective study of adult foot and ankle patients was performed over 6 months (October 2023-March 2024). At the time of preoperative evaluation, patients and their surgeon each independently completed a validated Foot and Ankle Surgery Expectations Survey, developed by the Hospital for Special Surgery. For each survey, the total number of expectations for which a respondent anticipated at least "a little improvement" were counted, giving the Number of Expected Areas of Improvement (NEAI); and a validated Aggregate Score (AS), capturing the overall magnitude of expectations, was calculated. Average NEAI and AS for each patient group were calculated and analyzed in regression models that included several demographic covariates.

Results: Sixty-nine patients were prospectively enrolled, 53 (76%) elective and 16 (24%) nonelective. The groups were demographically similar except for race. Patient expectations did not differ significantly between groups in NEAI or AS (P = .988, P = .462). Surgeon expectations were significantly lower both in NEAI and AS than those of patients in both groups (P < .001). Of the covariates tested in this study, increasing patient body mass index was the only significant predictor of increased patient-surgeon discrepancy (P = .005).

Conclusion: This study confirms previous findings that surgeons have lower preoperative expectations than patients who undergo orthopaedic foot and ankle surgery. This exploratory study suggests that neither patients' nor providers' overall expectations differ between elective and nonelective foot and ankle surgeries.

Level of evidence: Level III, prospective observational study.

Background: Although metatarsophalangeal joint (MTPJ) arthrodesis is considered the "gold standard" for treatment of advanced MTPJ arthritis, a modified oblique Keller capsular interposition arthroplasty (MOKCIA) is an alternative treatment for hallux rigidus that retains MTPJ motion. We aim to retrospectively compare long-term patient-reported outcomes, radiographic alignment, MTPJ walking kinematics, and plantar pressure between the MOKCIA and MTPJ arthrodesis for advanced hallux rigidus.

Methods: Thirty-five patients were recruited from a retrospective chart review (MOKCIA [n = 15, average 15 years from surgery] or an arthrodesis [n = 20, average 13 years from surgery]). We measured visual analog scale (VAS) pain and satisfaction, Foot and Ankle Ability Measure (FAAM), Patient-Reported Outcomes Measurement Information System (PROMIS) physical function scores, radiographs, walking MTPJ sagittal plane kinematics, forefoot, and first toe peak plantar pressure during walking, MTPJ goniometer range of motion, and need for additional surgery. Two-sample t tests or χ² were used to compare groups. A Spearman correlation was used to examine the relationships between measured variables.

Results: Groups did not differ on demographic characteristics, FAAM activities of daily living scale (MOKCIA = 94 ± 8, arthrodesis = 94 ± 7, P = .93), PROMIS physical function T-score (MOKCIA = 50 ± 6, arthrodesis = 48 ± 6, P = .41), forefoot, and first-toe walking peak plantar pressure. The MOKCIA had small but significantly lower VAS pain (MOKCIA = 0.1 ± 0.3, arthrodesis = 1.0 ± 1.6, P = .02) and higher satisfaction scores (MOKCIA = 9.5 ± 0.9, arthrodesis = 8.4 ± 1.8, P = .03). MTPJ passive arc of excursion in the MOKCIA group was 44 ± 15 degrees, and greater goniometric measured flexion of the first MTPJ correlated with greater patient satisfaction in the MOKCIA group (ρ = 0.70, P < .01). No MOKCIA patient in our study group required additional surgery.

Conclusion: Patients in both the MOKCIA and arthrodesis groups reported high function with little limitation due to their toe surgery. Patients in the MOKCIA group had similar pain and satisfaction compared with the arthrodesis group. These results suggest MOKCIA is a joint range of motion-preserving alternative to MTPJ arthrodesis for long-term treatment of hallux rigidus.

Level of evidence: Level III, retrospective, cohort study.