Foot & Ankle Orthopaedics最新文献

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.

Background: The use of fourth-generation minimally invasive hallux valgus surgery with metaphyseal extra-articular transverse and Akin osteotomy, recently dubbed "META," is a new generation of minimally invasive surgical (MIS) technique and a recent focus of foot and ankle orthopaedic literature associated with good functional outcomes and low complication rates. Literature in orthopaedic trauma has indicated that 2 or 3 neocortices on postoperative radiographs are associated with high likelihood of union. In this study, we conducted a retrospective analysis to investigate the time to bony union for patients undergoing fourth-generation MIS hallux valgus repair as well as the relationship between intraoperative degree of first-metatarsal displacement and time to bony union.

Methods: We retrospectively analyzed 217 consecutive patients with moderate to severe hallux valgus who underwent fourth-generation MIS first distal metatarsal and Akin osteotomy between 2020 and 2023 and were followed for up to 1 year. Radiographic measurements included the scale of displacement between the proximal and distal portions of the first metatarsal as a percentage and the number of neocortical bridge formations at the osteotomy site. Postoperative weightbearing radiographs were recorded at 6 weeks, 3 months, 6 months, and 1 year to assess time to union and patient clinical outcomes. Two orthopaedic surgeons independently reviewed the radiographs to assess progression to bony union. Any discrepancy in analysis was resolved by a third-party clinician. Complete union was defined as the presence of at least 2 new cortical bridge formations on postoperative X-ray films. Patients were divided into 3 groups based on the percentage of shift on the first metatarsal head (≤50%, 51%-75%, ≥76%) for the purpose of our analysis.

Results: Union (≥2 cortices) was observed in 17%, 70%, and 90% of patients at 6 weeks, 3 months, and 6 months, respectively. At final follow-up (mean 13 ± 6.9 weeks), 92% achieved union. No significant differences in time to union were observed across metatarsal shift groups.Complications include 3 nonunions, 3 revisions, 16 cases that necessitated removal of hardware, 1 case of superficial wound infection, 1 case of deep wound infection, and 6 deformity recurrences.

Conclusion: Time to union after META procedure typically occurred by 13 weeks, independent of shift magnitude. Surgeons may consider ≥2 cortices and absence of symptoms as sufficient indicators for advancing weightbearing. These findings may assist in patient counseling and postoperative planning.Level of Evidence: Level IV, retrospective case series.

Background: Minimally invasive or percutaneous surgery (MIS) for hallux valgus correction has seen increased adoption because of a growing evidence base of positive clinical and radiographic outcomes following surgery. However, no standardized or validated radiographic classification exists to evaluate the first metatarsal osteotomy healing following MIS hallux valgus surgery. The aim was to develop a new radiographic classification system for assessing bone healing following MIS distal transverse osteotomy for hallux valgus.

Methods: A 4-domain radiographic classification system based on callus formation, anteroposterior (AP) osteotomy line, lateral osteotomy line, and remodeling for MIS osteotomy healing was developed and tested on a cohort of 27 feet that underwent percutaneous transverse osteotomy for hallux valgus correction. Patients had simultaneous postoperative weightbearing computed tomography (WBCT) and standard radiographs following surgery. Five surgeons reviewed anonymized radiographs to evaluate interobserver reliability. WBCT was used to confirm union status and classification interpretation.

Results: The classification system demonstrated substantial interobserver reliability for lateral osteotomy line (Fleiss kappa = 0.671, 95% CI 0.505-0.814) and AP osteotomy line assessment (Fleiss kappa = 0.664, 95% CI 0.459-0.811), with moderate agreement for callus formation (κ = 0.465) and remodeling (κ = 0.439). The classification showed strong correlation with WBCT findings, with an optimal threshold of 8 points identified to differentiate union from nonunion, achieving an overall classification accuracy of 85.2%. This finding was supported by the area under the receiver operating characteristic (ROC) curve of 0.832. At the optimal threshold, the classification demonstrated 90.0% sensitivity and 71.4% specificity for detecting union.

Conclusion: This preliminary classification provides a reliable tool for assessing first metatarsal bone healing following MIS hallux valgus osteotomies, with substantial interobserver reliability. It offers a standardized approach for radiographic evaluation, which may enhance comparability across studies and serve as a radiographic research tool pending further validation. Its clinical applicability remains to be determined.

Level of evidence: Level III, diagnostic study.

Background: Recent advances in micro-computed tomography (MicroCT) imaging have enabled detailed investigations of human microvascular anatomy, providing new insights that may influence treatment options and optimize local reparative potential. This article describes a reproducible cadaveric perfusion technique for visualizing foot and ankle microvasculature using MicroCT, designed to support anatomical research and surgical planning studies.

Methods: Ten matched pairs of fresh-frozen cadaveric lower limbs were used to develop this protocol. An 18-gauge angiocatheter was used to cannulate the anterior and posterior tibial arteries for perfusion of the foot and ankle, or the popliteal artery for perfusion of the entire lower leg. Clearing was performed sequentially with 0.9% saline, 3% hydrogen peroxide, and water. Perfusion was performed with a 50% barium sulfate/2.5% gelatin solution. Confirmatory images were obtained using mini c-arm fluoroscopy. Final images were obtained for microvascular assessment using a commercial MicroCT scanner. Integrity of the perfusate was visually evaluated on MicroCT over the course of 4 freeze-thaw cycles spanning 2 months.

Results: All intraosseous and extraosseous microvascular structures were successfully visualized using MicroCT of the cadaveric lower extremities. Microvasculature was perfused in continuity without incidence of contrast extravasation. When present, intraosseous nutrient arteries of the first and fifth metatarsal, and branches of the tarsal sinus artery were appreciated. Contrast material remained visually consistent even after preforming surgical resections and undergoing multiple freeze-thaw cycles.

Conclusion: This standardized perfusion technique was effective in the visualization of microvasculature in the foot and ankle. In addition to 3-dimensional mapping using MicroCT, this reproducible protocol can be used in numerous advanced imaging applications, including microvascular assessment following surgical reconstructions and instrumentation.

Clinical relevance: A refined understanding of the microvascular anatomy of the foot and ankle using MicroCT perfusion imaging can potentially guide surgical techniques to minimize iatrogenic injury and optimize healing.

Background: Fractures of the toes are among the most frequently diagnosed lower extremity fractures. In sports, toe fractures may present after diverse mechanisms of injury, varying severity, and varying implications for management. This study aimed to discern trends in toe fractures presenting to US emergency departments (EDs) particularly in association with sports and recreational activities. An additional aim of the study was to identify if rates of toe fracture presentation significantly decreased during the year 2020 at the height of the COVID-19 pandemic.

Methods: We queried the National Electronic Injury Surveillance System (NEISS) database to identify toe fractures presented to US EDs from 2013 to 2022. The data outputs were analyzed by age group, sex, sport/recreational activity, and year. US Census data were used for calculation of incidence rates (IR) in 100,000 person-years. χ² tests and regression analyses were performed to determine significance. Grubbs's test was performed to determine significant yearly outliers with particular attention to the year 2020.

Results: A total of 921,033 toe fractures were identified across US EDs, with 175,864 cases associated with sports and recreation. Exercise (IR = 140.3) had the leading IR among sports/recreation followed by cycling (IR = 136.8), basketball (IR = 136.8), and football (IR = 94.9). Males accounted for 40.8% of fractures (IR = 23.0), whereas females contributed 59.2% (IR = 32.8). Toe fractures peaked in the 10- to 14-year-old age group in both males and females. Sports- and recreation-related toe fractures did not significantly decrease from 2013 to 2022, although all-cause toe fractures did significantly decrease as shown by a P value of .0037 from linear regression analysis of yearly trend in all toe fractures. The year 2020 was a significant outlier with a decrease in sports-related toe fractures though there was no significant decrease in all-cause toe fractures in 2020.

Conclusion: Sports- and recreation-related toe fractures did not significantly decrease from 2013 to 2022, although a significant decrease in all-cause toe fractures was observed. Toe fractures continue to peak in the pediatric age groups, particularly 10-14 year-olds. Youth sports and recreation officials should be aware of the risks of toe fractures to aid in prevention.Level of Evidence: Level III, epidemiologic database, retrospective cohort studies.