Foot & Ankle Orthopaedics最新文献

Background: Medial malleolus fractures (MMFs) are common across the world. Currently, there is a lack of consensus on the number of screws used in fixation of MMF. Our aim was to compare the radiographic outcomes of MMF with patients between fractures that have either undergone single-screw (SS) or dual-screw (DS) fixation.

Methods: This retrospective study assessed patients who had undergone fixation of their MMF from 2012 to 2022. Analysis of their perioperative radiographs was performed to determine the initial type of injury and then radiographic outcomes of nonunion and malunion.

Results: A total of 653 patients suffering bimalleolar fractures were identified across a 10-year period. There were 271 patients (41.50%) in the SS group and 382 in the DS group (58.50%). There was no difference found in the nonunion rate of SS (19.19% [52 of 271]) compared with DS (18.85% [72 of 382]) (P = .931). A statistically significant difference between malunion rates was found between the SS group (11.07% [30 of 271]) compared with the DS group (3.93% [15 of 382]) (P < .001).On multiregression analysis, factors that gained significance for development of nonunion was nonfixation of syndesmosis (P = .039), ankle dislocation on arrival (P < .001), and nonrestoration of fibular length (P < .001). Other factors that showed significance for failure to achieve medial anatomical reduction was nonfixation of syndesmosis (P < .001).

Conclusion: Use of an SS rather than DS showed a significant increase in nonanatomical reduction but did not increase nonunion or reoperation rate. Syndesmosis fixation was associated with higher rates of MMF nonunion and malunion; as such, surgeons should have a low index of suspicion of injury and fixation.

Level of evidence: Level III, retrospective case series.

Background: One factor contributing to rotational deformity of the first metatarsal in hallux valgus is torsion of the metatarsal itself. Hallux rigidus also involves reduction of the longitudinal arch, but metatarsal torsion has not been discussed. We hypothesized that metatarsal torsion may be a morphologic change unique to hallux valgus. We compared 3-dimensional (3D) torsion of the first to fifth metatarsals between feet with hallux valgus, feet with hallux rigidus, and healthy control feet to investigate differences in the effects on pathologic conditions.

Methods: Participants were women of East Asian descent. There were 16, 16, and 14 feet in the control, hallux valgus, and hallux rigidus groups, respectively. One randomly selected control foot was designated as the reference foot. For comparison, nonweightbearing computed tomography images of the metatarsals were reconstructed in 3D, and the proximal and distal areas were superimposed on the reference foot. Torsion angle was defined as the rotational angle of the distal part of the articular axis relative to the proximal area. In the hallux valgus group, correlations of torsion angle with hallux valgus angle and intermetatarsal angle were calculated.

Results: The hallux valgus group had greater average pronation torsion in the first metatarsal than the control group and hallux rigidus group (11 and 13 degrees greater, respectively, P < .01). No significant differences were observed for the second to fifth metatarsals (P > .05). There was no significant correlation with hallux valgus angle or first-second intermetatarsal angle in the hallux valgus group (P > .05).

Conclusion: Hallux valgus feet had pronation deformities in the first metatarsals not observed in control or hallux rigidus feet, meaning that torsion toward pronation (eversion) in the first metatarsal was unique to hallux valgus. Improved surgical correction to diminish pronation may be necessary in patients with hallux valgus patients because of first metatarsal pronation in the first tarsometatarsal to normalize mechanical first-ray alignment.Level of Evidence: Level III, case-control stud.

Background: Total ankle arthroplasty has emerged as a treatment to successfully treat ankle arthritis. Recent studies have reported more than 40 000 total ankle arthroplasties (TAAs) being performed between 2009 and 2019 in the United States. Although recent studies have reported favorable patient-reported outcomes at short- and midterm follow-up, there is a paucity of aggregate literature reporting on long-term patient-reported outcomes (PROs) after TAA. The purpose of this review is to report an aggregate of literature on minimum 10-year patient-reported outcomes after TAA.

Methods: A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. PubMed, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL) were queried in June 2024. Primary research articles were included if they reported minimum 10-year PROs or satisfaction for patients who underwent primary TAA and were written in English. Survivorship was reported based on implant failure, which was determined uniquely by each study.

Results: Eight studies met the inclusion criteria. A total of 595 ankles with a range of average ages from 51 to 73.7 years were included in the study with follow-up ranging from a minimum of 10 years to a minimum of 20 years. Six of the 8 studies reported average follow-up ranging from 11.9 to 15.8 years. Two of the 8 studies reported significant improvement in PROs following surgery. Survivorship at a minimum of 10-year follow-up ranged from 66% to 94.4%. Average time to implant failure ranged from 4.6 to 13.8 years.

Conclusion: Patients undergoing primary TAA were reported to have generally improved PROs at minimum 10- year follow-up. However, they demonstrated variable rates of survivorship ranging from 66% to 94.4%. Of those experiencing implant failure, average time to failure ranged from 4.6 to 13.8 years. Survivorship should be interpreted with caution because of varying definitions between studies. Further studies should seek to standardize the definition of survivorship and reporting of PROs to allow for effective analysis of heterogeneity.

Background: Anatomical reduction of posterior malleolar fracture is a key goal in achieving good functional outcomes in patients with ankle fractures. Although there are many approaches for managing this type of fracture, no studies have shown reduction quality of posterior malleolar fracture in postoperative CT scan using the modified posteromedial ankle approach.

Methods: A retrospective case series of 66 patients of 2 health centers with type 2, 3, and 4 posterior malleolar fractures according to Bartonicek classification treated using the modified posteromedial ankle approach was performed. The postoperative CT scan was used to assess syndesmotic reduction and articular step-off and residual gap in posterior malleolus reduction.

Results: Reduction of posterior malleolus fracture was determined to be <2 mm in 62 patients and >2 mm in 4 cases. Syndesmotic reduction quality was considered to be anatomical in 61 patients. Four patients showed mild anterior fibular translation in the axial plane and were not reoperated. One syndesmotic malreduction was considered poor.

Conclusion: In this study, we found that 92% (61 of 66) of patients with posterior malleolar fracture were reduced with <2 mm step-off using this modified posteromedial ankle approach and fracture fixation strategy.

Level of evidence: Level IV, case series.

Background: The impact of social health on patient-reported outcomes (PROs) is gaining increasing attention within the orthopaedic community. Few studies have explored any relationship between social deprivation levels and PROs in orthopaedic foot and ankle patients.

Methods: We retrospectively identified patients who presented to an orthopaedic foot and ankle clinic for new evaluation. Patients completed PROs including PROMIS physical function (PF), PROMIS pain interference (PI), and the Foot and Ankle Ability Measure (FAAM). Social deprivation was measured using the Area Deprivation Index (ADI), a metric that incorporates various domains of poverty, education, housing, and employment. The ADI score quantifies the degree of social deprivation based on the 9-digit home zip code but is not a specific measure to an individual patient. Briefly, a lower ADI indicates less deprivation whereas a higher score denotes greater deprivation. Patient characteristics and outcomes were summarized and stratified by the nationally defined median ADI. Multivariable linear regression models assessed the relationships between PROs and continuous ADI controlling for demographics (age, sex, race/ethnicity, marital status, and employment status).

Results: Our cohort consisted of 1565 patients with PRO and appropriate zip code data. Patients in the most-deprived median ADI split had more pain (median PROMIS-PI 62.7 vs 61.2, P = .001) and less function (median PROMIS-PF 37.1 vs 38.6, P = .021) compared with the least-deprived median ADI split. The clinical significance of these findings is unclear, though, given the minimal differences between groups for PROMIS measures. There was no relationship between ADI and FAAM scores.

Conclusion: More socially deprived patients presented to the clinic with marginally less function and greater pain. Although statistically significant, the clinical significance of these relationships is unclear and merits further exploration. We plan to continue to study the connection between social deprivation and patient outcomes in specific clinical conditions as well as before/after surgical interventions.

Level of evidence: Level IV, retrospective cases series.

Background: Zone II and III fifth metatarsal (5-MT) fractures among athletes are typically managed with percutaneous fixation following anatomic reduction. However, screw head discomfort and refracture after bone union can occur because of the loads placed on the foot during play. Several hardware systems that use a smaller screw head compared to traditional hardware systems have been developed to minimize the rate of postoperative hardware complications. This study compares clinical and radiographic outcomes of 5-MT fractures in elite athletes treated with a solid headless screw vs a solid headed screw. We hypothesized that the headless screw would be associated with faster union rates, faster clearance times, and lower incidence of symptomatic hardware compared to the headed screw.

Methods: Athletes competing at a collegiate level or higher treated for a zone II or III 5-MT fracture between 2016 and 2022 by 2 surgeons fellowship-trained in foot and ankle orthopaedics were screened. Operative notes were reviewed to determine the hardware system used. Subjects were divided based on the hardware system used during operation: headed screw and headless screw. Time to radiographic union, time to full clearance, and return to competition were determined. Postoperative complications, including nonunions, need for revision, need for hardware removal, and refractures were also noted.

Results: Forty eligible patients (44 feet) were identified. The solid headed screw group included 20 patients (21 fractures), and the solid headless screw group included 20 patients (23 fractures). Average time to union for the headed screw group was 11.78 (range, 5.86-19.00) weeks; average time to union for the headless screw group was 11.65 (range, 6.00-22.57) weeks (P = .93). Nineteen out of twenty (95%) patients were able to return to competition in both groups. Average time to return to competition for the headed screw group was 26.9 (range, 10.00-47.86) weeks, while average time for the headless screw group was 21.2 (range, 6.86-55.00) weeks (P = .55). The overall complication rate for the headed screw was 23.8%, which was not statistically different from the overall complication rate for the headless screw of 13.0% (P = .35).

Conclusion: In this relatively small sample of elite athletes undergoing operative fixation of a 5-MT fracture, fixation using either a headless or headed screw system had similar good outcomes in regard to times to union, return to competition, and complication rate regardless of solid screw head type used.

Level of evidence: Level III, retrospective cohort study.

Background: Lisfranc injuries are often managed surgically with primary arthrodesis (PA) or open reduction and internal fixation (ORIF); however, neither approach has been shown to be superior. This systematic review and meta-analysis assessed randomized controlled trials (RCTs) to compare the functional and surgical outcomes of PA and ORIF in the treatment of Lisfranc injuries.

Methods: This study was performed as per the PRISMA protocol. Database searches were conducted on Cochrane, Embase, and PubMed libraries. Five RCTs were identified for inclusion involving 241 patients, of which 121 underwent PA and 120 underwent ORIF.

Results: Statistically significant differences in visual analog scale pain score at 2 years (mean difference 0.89, 95% CI 0.18-1.59), patient satisfaction (OR 10.04, 95% CI 1.78-56.76), and all-cause return to surgery (OR 27.31, 95% CI 12.72-58.63) were observed, all favoring PA. There were no statistically significant differences between PA and ORIF with regard to American Orthopaedic Foot & Ankle Society midfoot scores at 2 years, 36-Item Short Form Health Survey (SF-36) scores, and unplanned return to surgery.

Conclusion: This study showed significant improvement in pain at 2 years, patient satisfaction, and all-cause return to surgery favoring PA in all instances. Given ORIF often necessitates a second operation for hardware removal, it is to be expected that all-cause return to surgery is higher in ORIF groups. Overall, these results do not have the power to confer an advantage to a particular approach because of significant heterogeneity. Further studies should focus on larger patient cohorts and longer follow-up, or analysis stratified by patient demographics and injury presentation. In the absence of clinically significant differences, cost-benefit analyses should be considered to answer the question of whether to "fix or fuse" for Lisfranc injuries.

Background: The posterior tibial tendon (PTT), deltoid ligament, and spring ligament are often torn or attenuated in patients with progressive collapsing foot deformity. The goal of this pilot study was to measure the ultrasound shear wave velocity (SWV) of these arch-supporting structures in feet with varying degrees of deformity to improve our understanding of their role in the progression of deformity.

Methods: Two observers measured the SWV of the supramalleolar and inframalleolar PTT in long and short axes, in the tibiospring portion of the deltoid ligament, and in the superomedial band of the spring ligament in 8 neutrally aligned feet, 5 asymptomatic flatfeet, and 7 symptomatic flatfeet. Each measurement was repeated 3 times both with and without an applied eversion stress.

Results: Average SWV was lower at all locations in the symptomatic flatfeet compared with normal feet, but these differences were statistically significant only for the inframalleolar PTT and the spring ligament. Externally applied stress led to an increase in the SWV of the ligaments but a paradoxical decrease in the SWV in the supramalleolar PTT. The SWV of the PTT was lower along the short axis compared with the long axis.

Conclusion: SWV may be useful in evaluating the severity of degenerative disease of arch-supporting structures, but further study is needed before this technique can be applied clinically.

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

Background: Insertional Achilles tendinopathy (IAT) is often surgically treated with Achilles tendon partial or total detachment, debridement and repair of the Achilles tendon, excision of retrocalcaneal exostosis, and suture anchor reattachment. To date, there is no report that examines the use of acellular dermal matrix (ADM) augmentation in this procedure without the use of suture anchor reattachment.

Methods: Thirty-two female and 10 male patients (mean age 52 years) with IAT underwent surgical treatment including partial detachment of the Achilles tendon, excision of the retrocalcaneal exostosis, debridement and repair of the Achilles tendon, and augmentation with human acellular dermal matrix allograft. Outcomes measured were the visual analog scale (VAS) score, time to weightbearing, major and minor complications.

Results: Forty-two patients were followed for a mean of 20.8 months. The VAS score improved from a mean of 5.1 to 1.9 at final follow-up. The mean time to weightbearing was 4.4 weeks. Eleven patients (26.2%) experienced complications. One patient (2.4%) suffered a rupture of the Achilles in the early postoperative period. Three patients (7.1%) had delayed wound healing, with 1 (2.4%) requiring surgical debridement. Two (4.8%) experienced continued pain requiring further surgical treatment.

Conclusion: This protocol for surgical treatment of IAT with the use of human ADM allograft augmentation resulted in improved VAS scores and was associated with a low risk of postoperative infection without a prolonged nonweightbearing period.

Level of evidence: Level IV, retrospective case series.

Background: Treatment pathways of fifth metatarsal fractures are commonly directed based on fracture classification, with particular proximal fractures typically requiring closer observation and possibly more aggressive management. Our aim is to investigate the interobserver reliability of assessment of subtypes of fifth metatarsal fractures.

Methods: We included all patients referred to our virtual fracture clinic with a suspected or confirmed fifth metatarsal fracture. Plain anteroposterior radiographs were reviewed by 2 novice observers, initially trained on the fifth metatarsal classification identification. Eight different zones were defined based on anatomical location. Patients were excluded from analysis if neither observer could identify a fracture. An interobserver reliability analysis using Cohen κ coefficient was carried out, and degree of observer agreement described using Landis and Koch's description. All data were analyzed using IBM SPSS, version 27.

Results: A total of 1360 patients who met the inclusion criteria were identified. The 2 observers had moderate agreement when identifying fractures in all zones, apart from zone 1.2 and distal metaphysis (DM) fractures, which only achieved fair agreement (κ = 0.308 and 0.381 respectively). Zone 3 has slight agreement with zone 2 proximally, and there is an apparent difficulty with distal diaphyseal shaft (DS) fractures, resulting in a lot of crossover with DM, achieving a fair level of agreement (DS 312 vs 196; DM 120 vs 237; κ = .398, P < .001).

Conclusion: Reliability of subcategorizing fifth metatarsal fractures using standardized instructions conveys moderate agreement in most cases. If the region of the fracture is going to be used in an algorithm to guide a management plan and clinical follow-up during a virtual clinic review, defining fractures of zones 1-3 needs careful consideration.

Level of evidence: Level III, retrospective cohort study.