Foot & Ankle Orthopaedics最新文献

Background: This study evaluated postoperative outcomes following Lapidus arthrodesis (fusion of the first tarsometatarsal joint [TMT1]) using two nitinol staples for hallux valgus correction, focusing on fusion rate, reoperation rate, and patient satisfaction.

Methods: A total of 60 cases undergoing Lapidus arthrodesis between June 2018 and June 2022 were analyzed with a median follow-up of 37 months (range: 15-64 months). All cases were treated using two nitinol staples (BME Elite^TM; DePuy Synthes) for TMT1 fusion. Among these, 38 cases involved additional foot procedures, while 22 cases had isolated TMT1 fusion. Data were collected from medical records, radiographs, and a telephone survey. The hallux valgus angle (HVA) and intermetatarsal angle (IMA) were measured preoperatively and postoperatively on weightbearing dorsoplantar radiographs. Functional outcomes were assessed using the Foot and Ankle Ability Measure-Activities of Daily Living (FAAM-ADL) subscale, and patient satisfaction was evaluated using a 4-point Likert scale.

Results: The TMT1 fusion rate was 96.7% (58/60). The reoperation rate-including hardware removal, revision surgery for recurrence, and nonunion-was 16.7%. The staple breakage rate was 3.3%. The IMA improved from 15.8 to 8.9 degrees (P < .001), and the HVA improved from 37.5 to 17.3 degrees (P < .001). The average FAAM-ADL score was 81.7 out of 84, with 90% of patients reporting being very satisfied or satisfied.

Conclusion: The Lapidus arthrodesis, fixed with nitinol staples, resulted in high rates of fusion and patient satisfaction.

Level of evidence: IV, retrospective cohort study.

Background: Ligamentous pathologies and injuries of the foot and ankle commonly require surgical repair. Ligament augmentation techniques (LAT) use a synthetic ligament that spans the anatomic length of the injured ligament, anchoring to bone on both ends. Use of LAT in foot and ankle surgery is rapidly progressing, but the rates of usage and surgeon-specific indications are not well known. This study aims to provide an in-depth analysis of LAT use by foot and ankle surgeons.

Methods: An online survey was distributed to the surgeon members of the American Orthopaedic Foot & Ankle Society (AOFAS). Survey questions detailed demographics and practice details, current use of LATs, and the future trajectory of LATs. Responses were tabulated and summarized. Logistic regression and χ2 tests of independence compared trends in LAT use between North America and outside continent, years in practice, and type of practice.

Results: Of 1895 invited surgeons, 244 (12.9%) completed the survey. Among respondents, 209 surgeons (85.7%) reported current LAT use, most of whom were based in North America (197, 80.7%). North American respondents were significantly more likely to report using LAT when compared to respondents outside of North America (89% vs 72% respectively) (P = .007). The 3 most common ligaments for LAT use were the ATFL (205, 98.1%) followed by the syndesmosis ligament (125, 59.8%) and the deltoid ligament (122, 58.4%). The most common reason for LAT use was faster return to sport (136, 65.1%). More than half of respondents (131, 53.6%) anticipate increased LAT in the future.

Conclusion: LAT use in foot and ankle surgery is multifactorial, influenced by patient demographics, regional practices, industry dynamics, and surgeon training. Ongoing debates about the cost-effectiveness and long-term outcomes of LAT suggest that further research is necessary to fully define its role in orthopaedic foot and ankle surgery.

Level of evidence: Level V, therapeutic.

Graphical Abstract.

Background: The choice between locking and nonlocking plates for ankle fracture fixation is guided by implant cost, patient factors, fracture morphology, and clinical outcomes. Locking plates offer increased stability, particularly in osteopenic bone, and are available in low-profile, anatomically precontoured designs, though they are generally less malleable than nonlocking plates and are associated with higher cost. This study evaluates the cost-effectiveness of these methods by PROMIS (Patient-Reported Outcomes Measurement Information System) scores and complication rates. The primary outcome was defined as postoperative PROMIS pain interference and physical function scores.

Methods: We conducted a retrospective review of ankle fracture fixations at our institution from 2016 to 2021. Surgical cost, outcome, and complication data were obtained through chart reviews. PROMIS scores were collected via structured telephonic interviews. PROMIS scores were analyzed with 2-sided t tests (Python 3.11.4, SciPy). Complication rates were evaluated with χ² tests (Python 3.11.4, statsmodels).

Results: Of 493 patients, 283 received locking plate fixation and 210 nonlocking. Locking plate fixations cost 3.61 (95% CI: 2.81-4.64) times as much as nonlocking plate fixations, and reoperations cost 4.15 (95% CI: 1.11-15.47) times more. PROMIS pain interference and physical function scores did not differ significantly. Complications requiring reoperation occurred in 17.31% of locking plate patients and 21.9% of nonlocking plate patients (P = .20). Hardware removal occurred more often in the nonlocking group (P < .001), whereas infection was more frequent with locking plates (P < .05).

Conclusion: Locking plates are significantly more expensive than nonlocking plates and did not demonstrate statistically significant differences in union rates, complication rates, or PROMIS scores between patients in this retrospective cohort. However, nonlocking plates had higher rates of uncomplicated syndesmotic screw removal rate whereas locking plates were associated with increased deep infection, resulting in a greater cost of reoperation compared with nonlocking plates. Although conclusions are limited by the study's retrospective nature and a significantly greater proportion of elderly and female patients in the locking plate cohort, it appears to demonstrate similar PROMIS scores and union rates outcomes.

Level of evidence: Level III, retrospective cohort study.

Background: In recent years, there has been an increased push for diversity in orthopaedics at the residency level. There has also been a noticeable shift away from foot and ankle fellowship, with many fellowship positions open throughout the country annually. With the increase in osteopathic and female orthopaedic applications to orthopaedic surgery residency, we hypothesized that this would be reflected in the foot and ankle fellowship applications in the last decade.

Methods: The San Franscisco Match data from 2012 to 2023 were analyzed for degree type and from 2013 to 2023 for gender. There were 1082 applicants for adult foot and ankle fellowships from 2012 to 2023, 74 osteopathic applicants (11.4%), and 573 allopathic applicants (88.6%). There were 126 female applicants (21.3%) and 465 male applicants (78.7%). The 435 international graduates were excluded from this analysis. The degree type, gender, number of applicants, and number of applicants matched into orthopaedic foot and ankle fellowship was reviewed.

Results: The number of osteopathic applicants and female applications did not change significantly over the study period. There was a statistically significant decrease in the number of allopathic applicants (P = .003) and a significant decrease in the number of male applicants to foot and ankle fellowship (P = .00004). The match rate for allopathic, osteopathic, and male applicants all statistically increased over the study periods, whereas the female applicant match rate remained stable. Programs tended to rank their matched allopathic residents higher, whereas osteopathic applicants' position in the fellowship program rank list remained steady. Female and male applicants matched at programs higher on their rank lists, whereas programs match applicants lower on theirs.

Conclusion: More orthopaedic foot and ankle surgeons are needed nationwide. Understanding recent trends in applicant demographics and match outcomes may help inform strategies to increase interest and participation in this subspecialty.

Level of evidence: IV, cross-sectional study.

Background: Swelling following an ankle fracture is commonly believed to preclude surgical fixation; swelling is thought to be associated with increased wound complications. Delaying surgery until swelling subsides is thought to secure better outcomes, although no guidelines exist to direct surgeons when an appropriate time to intervention is or whether a visual inspection of the swelling is correlated to quantitative measurement. This study aimed to identify whether preoperative ankle swelling influences postoperative wound complications following ankle fracture surgery.

Methods: This prospective cohort study recruited patients undergoing operative management of closed rotational ankle fractures on a single side (unilateral injury). Individual surgeons determined the time to surgery based on their usual practice. Ankle swelling was measured on a subjective visual scale and then quantitatively using the validated figure-of-8 technique. Follow-up was standardized at 2, 6, and 12 weeks postoperatively. Between-group participant, surgical, and wound characteristics were recorded and analyzed, in addition to the agreement between qualitative and quantitative ankle-swelling measures.

Results: Eighty participants were recruited. The wound complication rate was 8.75% (n = 7), with only 1 deep infection requiring operative intervention and antibiotic therapy. Wound complication rates were not associated with quantitative ankle swelling (P = .76), visual assessment of ankle swelling (P = .65), or time to operative intervention (P = .27). Increasing age (P = .006) and female gender (P = .034) were associated with wound complications. Between-group body mass index, experience level of the operating surgeon, and tourniquet time were not statistically significant. Visual assessment of ankle swelling had a poor to moderate correlation to "figure-of-8' ankle swelling measurements (intraclass correlation = 0.507, 95% CI = 0.325-0.653).

Conclusion: In this prospective and underpowered study, we did not find that time to surgical intervention or residual swelling at the time of surgery was associated with increased wound complications following fixation of closed unilateral malleolar ankle fractures, including those involving multiple malleoli. Although surgeon discretion was used in determining readiness for surgery, all cases had some delay, which may have influenced results. Visual assessment of swelling showed only moderate correlation with objective measurement, questioning its reliability as a surgical readiness tool.These findings suggest that in carefully selected cases, delaying surgery beyond initial clinical readiness for reasons of residual swelling may not be necessary.

Level of evidence: Level II, prospective cohort study.