Foot & Ankle Orthopaedics最新文献

Background: Foot injuries are often missed in polytrauma patients, as more severe injuries may overshadow them, leading to delayed diagnosis and treatment. The aim of this study was to assess the incidence of foot injuries in polytrauma patients, evaluate the timing of their diagnosis, and identify risk factors associated with delayed diagnosis.

Methods: In this retrospective registry-based study, all polytrauma patients with a New Injury Severity Score of ≥16 treated at Tampere University Hospital (TAUH) from 2016 to 2023 were screened for foot fractures as well as Lisfranc and Chopart injuries. Patient demographics, injury characteristics, and timing of diagnosis were extracted from TAUH's trauma registry and analyzed.

Results: Out of 1327 polytrauma patients, 54 (4.1%) sustained foot injuries, totalling 215 foot injuries (195 fractures). Delayed diagnosis, defined as >24 hours between trauma and diagnosis, occurred in 23 patients (43%), involving 80 injuries (37%). Fractures of the midfoot and metatarsus were most commonly diagnosed with delay. Delayed diagnosis was significantly more common in patients with a higher number of foot fractures and injuries (P < .001). Logistic regression analysis identified number of foot injuries (OR 1.658 [95% CI 1.098-2.504 ]), lower Glasgow Coma Scale (GCS) scores (OR 0.582 [95% CI 0.340-0.998]), and presence of concomitant facial injuries (OR 18.227 [95% CI 1.643-202.211]) as independent risk factors for delay in diagnosis.

Conclusion: A substantial portion of polytrauma patients had foot injuries that were diagnosed >24 hours after the time of trauma. Despite these delays, most injuries were minor and without notable clinical consequences. Current tertiary survey protocols effectively detect most major foot injuries requiring immediate attention.

Level of evidence: Level III, retrospective registry.

Background: In orthopaedic foot and ankle procedures, bone debris generated during osteotomies is typically discarded. However, this autograft bone debris has good handling properties and can be amenable for use as a stimulus to bone healing at the site of the osteotomy.

Methods: In the present study, discarded bone debris was harvested intraoperatively during minimally invasive chevron Akin (MICA) hallux valgus corrections, isolated Akin osteotomies of the proximal phalanx of the great toe, cheilectomies, and calcaneal osteotomies from 9 participants.

Results: Multiplex protein arrays of 40 cytokines and 41 growth factors identified 76 immunomodulatory and reparative proteins within the bone debris. Fifteen key growth factors and cytokines (VEGF, PDGF-BB, M-CSF, EGF-R, HGF, ICAM1, GCSF, TIMP-2, sTNFRII, MCP-1, GM-CSF, IL-6sR, IL-10, MCP-2, RANTES) were prominent, suggesting that bone debris proteins may have potential effects on immunomodulation and bone regeneration including cytokine-cytokine receptor interaction, interleukins, MAPK, PI3K-Akt, Wnt, BMP, and TGFβ signaling pathways.Mesenchymal stem/stromal cells (MSCs) were isolated from bone debris of the osteotomies. MSCs expressed genes involved in bone and cartilage formation, homeostasis, angiogenesis, and immunomodulation. Fourteen genes were associated with maintaining cell stemness, whereas seventeen genes were linked to osteochondral development and spatial organization. Additionally, the study identified eight genes promoting angiogenesis and ten genes regulating immune responses in the mesenchymal stem cell environment.

Conclusion: This repurposed surgical waste contains a concentrated array of growth factors, antiinflammatory mediators, and viable MSC that might enhance bone healing when reintroduced to surgical sites.

Clinical relevance: The results could serve as a foundation for repurposing previously discarded bone debris as autologous bone grafts for reimplantation in minimally invasive orthopaedic procedures to potentially enhance bone tissue healing. To confirm clinical relevance, further well-controlled trials are required to establish whether these findings improve bone healing rates and related patient-reported outcomes.

Background: Chronic kidney disease (CKD) is a recognized risk factor for adverse outcomes in total hip and knee arthroplasties; however, its impact on total ankle arthroplasty (TAA) outcomes is limited. This study investigates the association between CKD severity and 30-day postoperative outcomes following TAA.

Methods: We analyzed the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database for primary TAAs between 2006 to 2021. Estimated glomerular filtration rate (eGFR) was calculated, categorizing patients into CKD stages. Univariable analysis assessed associations between eGFR categories, demographic characteristics, and outcomes. Multivariable regression models were used to identify predictors of hospital length of stay, unplanned return to the operating room, and overall complications.

Results: Of the 1678 eligible primary TAA cases, 675 were G1, 806 G2, 136 G3a, 50 G3b, 7 G4, and 4 G5. Significant differences across eGFR categories were found for age, sex, race, anesthesia type, diabetes, hypertension, postoperative dialysis, American Society of Anesthesiologists class, blood urea nitrogen, creatinine, white blood cell count, and hematocrit. The overall complication rate was 3% (53/1678). Rates of myocardial infarction, unplanned return to surgery, and hospital length of stay differed significantly among eGFR groups. Multivariable negative binomial regression identified predictors of longer hospital stay including age 80-89 years, male sex, American Indian / Alaska Native race, unknown race, partial functional dependency, monitored anesthesia care/intravenous sedation, insulin-dependent diabetes, greater or equal to 2 direct complications, and 1 indirect complication. Notably, CKD stage G3b was associated with significantly longer stays compared with G1. Logistic regression revealed that 1 or greater or equal to 2 direct complications and CKD stages G4+G5 significantly predicted unplanned return to surgery. Smokers experienced higher overall complication rates.

Conclusion: In this retrospective observational study, we found that CKD severity significantly impacts postoperative outcomes following TAA, with advanced stages linked to prolonged hospital stays and increased risk of unplanned return to surgery.

Level of evidence: Level III, retrospective cohort series.

Background: Pilon fractures of the distal tibial plafond account for 1% to 10% of all tibial fractures and are often associated with serious complications. As body mass index (BMI) is known to impact post-operative outcomes, particularly infection and nonunion, after trauma, the goal of this study is to explore these trends after pilon fractures.

Methods: A single-center retrospective review of patients undergoing surgical fixation for pilon fractures between January 2013 and June 2023 was conducted. Only patients with at least a 6-month follow-up period were included. Demographic data and injury characteristics were extracted. Post-operative outcomes and complications were computed. Bivariate analysis via t test were applied, followed by multivariate analysis using primary and reduced models to evaluate for poor outcomes. Various BMI cutoffs (≥30, ≥35, ≥40, ≥45) were also employed to evaluate the relationship between outcomes and various obesity categories. Nonunion was assessed at ≥6 months postoperatively.

Results: There were 132 patients included. There was no significant relationship between BMI and infection rates, nonunion rates, and development of post-traumatic osteoarthritis (PTOA) on bivariate analysis (P > .05). On multivariate analysis, diabetes mellitus was a risk factor for infection (P = .01), but BMI was not predictive of any outcomes in the primary or reduced models (P > .05). There were no significant differences in infection, nonunion, and PTOA rates when employing various BMI cutoffs (P > .05).

Discussion: BMI was not found to be an independent predictor of post-operative complications in patients with pilon fractures in this cohort. Our study suggests that pilon fractures are unique and counter historic lower-extremity injury postoperative care protocols that consider weight, although further investigation in larger cohorts with long-term follow-up is required to define this trend.

Level of evidence: Level III, retrospective cohort series.

Background: Injuries to the lateral collateral ligament (LCL) of the first metatarsophalangeal (MTP) joint that are treated surgically are rare. We present 3 cases of traumatic LCL injury of the first MTP joint that were treated surgically for a Stener-like lesion preventing healing. Additionally, we present a review of previously published cases.

Methods: Diagnosis was confirmed with magnetic resonance imaging and intraoperative stress tests, which demonstrated instability and LCL disruption with interposition of the adductor hallucis aponeurosis. All cases were managed operatively with suture anchor repair at the LCL origin or insertion. Patients were followed for 2-4 years postoperatively with outcomes assessed using the Foot and Ankle Outcome Score (FAOS) and the American Orthopaedic Foot & Ankle Society (AOFAS) Hallux Score.

Results: Three LCL repairs were performed in 2 patients, including 1 with bilateral injuries. At final follow-up, both patients had returned to high-level athletic activity. The mean FAOS was 97% and the mean AOFAS Hallux Score was 91.67%. Literature review identified 10 prior case reports with heterogeneous surgical techniques but consistently favorable outcomes.

Conclusion: This series presents a pattern of traumatic LCL injuries with a Stener-like lesion of the great toe that were treated with surgical repair and, to our knowledge, represents the first review of reported cases, offering a synthesis of diagnostic features, operative technique, and outcomes.

Level of evidence: Level IV, case series.

Background: Chronic opioid use has been linked to adverse surgical outcomes, yet its impact on ankle fracture surgery remains underexplored. This study evaluates the association between preoperative opioid use and postoperative health care utilization in patients undergoing surgical fixation for an isolated ankle fracture.

Methods: A retrospective cohort study was conducted at a level 1 trauma center over a 2-year period. Patients who underwent surgical fixation for an isolated ankle fracture were identified using Current Procedural Terminology (CPT) codes. Those with concurrent orthopaedic injuries or insufficient follow-up data were excluded. Patients were categorized as long-term opioid users (>3 months of opioid use) or opioid-naïve. Electronic medical records were reviewed to obtain data on patient demographics, comorbidities, injury characteristics, length of stay, opioid prescriptions, and 90-day postoperative outcomes, including emergency department (ED) visits, readmissions, and reoperations. Bivariate and multivariate analyses were used to assess the impact of opioid use on postoperative complications and health care utilization.

Results: Of the 303 patients analyzed, 40 (13.2%) were long-term opioid users. Compared with opioid-naïve patients, opioid users had significantly longer hospital stays (5.3 ± 6.1 vs 2.6 ± 2.9 days, P < .001) and higher rates of 90-day ED visits (0.55 ± 1.11 vs 0.24 ± 0.61, P = .010), unplanned readmissions (0.33 ± 0.69 vs 0.076 ± 0.33, P < .001), and unplanned reoperations (0.18 ± 0.59 vs 0.05 ± 0.26, P = .026). Pain-related complaints were the most common reason for postoperative ED visits among opioid users. Logistic regression identified psychiatric history and hospital length of stay as independent predictors of increased readmissions, and hospital length of stay an independent predictor of postoperative ED visits. Opioid use alone was not predictive of readmissions or ED visits.

Conclusion: Preoperative opioid use is linked to longer hospital stays and increased postoperative health care utilization on unadjusted analyses. In multivariable models, psychiatric history and hospital length of stay, rather than opioid use alone, were independent predictors of readmissions and ED visits, suggesting that addressing psychiatric comorbidities and optimizing pain management strategies may improve outcomes in this patient population.

Level of evidence: Level III, retrospective cohort study.

Background: Rigid hammertoe deformities in diabetic patients present a therapeutic challenge: percutaneous tenotomy often fails to address capsular contractures, whereas arthrodesis carries an elevated risk of complications. We hypothesized that combining tenotomy with plantar capsule release would provide effective correction while preserving neurovascular structures. This study evaluates the feasibility correction magnitude and vascular safety of this technique through a cadaveric model.

Methods: We perfused 10 clinical-grade lower-limb cadaveric specimens, possessing 14 rigid hammertoes (N = 14), with an India ink-latex mixture to highlight vascular structures. Specimens with significant pathology or prior forefoot surgeries were excluded. The angle of the hammertoe deformity was measured using a goniometer preoperatively, after percutaneous flexor tenotomy, and again after releasing the plantar capsule. Standard dissection was then conducted to assess the common plantar digital arteries.

Results: Mean preoperative contracture of 56.5 (range 15-86) degrees improved to 26.8 (range 0-60) degrees (47.4%) after tenotomy of the flexor digitorum brevis and longus tendons, with 1 toe releasing fully. In cases where full release was not achieved following tenotomy, plantar capsule release was performed. Full release was obtained in 92% of the cases undergoing plantar capsule release. Importantly, no iatrogenic injury occurred to the plantar medial and lateral digital arteries during the procedure.

Conclusion: In cadaveric specimens, partial release of the rigid hammertoe deformity was seen following flexor tenotomy in all but 1 toe. The addition of a proximal interphalangeal joint plantar capsule release was effective at obtaining full release, without evidence of vascular injury. As such, combining tenotomy with plantar capsule release showed effective correction in this cadaveric model and may represent a less invasive option for correcting rigid hammertoes in an outpatient setting.

Level of evidence: Level V, expert opinion includes case reports and technique tips.

Clinical relevance: This technique may offer diabetic patients a lower-risk alternative to arthrodesis, potentially reducing ulcer-related amputations through earlier intervention in outpatient settings.

Background: Charcot foot, characterized by progressive osseous and articular destruction, necessitates early diagnosis and a multidisciplinary approach to prevent severe complications. This study assessed the efficacy of an educational intervention in improving radiographic detection and referral for Charcot foot among health care professionals.

Methods: Thirty health care professionals, including foot and ankle surgeons (FAs), orthopaedic/trauma specialists (OTs), and family physicians (FDs), participated in this quasi-experimental, pre-post study. Participants completed a baseline assessment and received an educational intervention (face-to-face/webinar or self-directed PDF), followed by a reassessment. Primary outcomes included changes in diagnostic and referral accuracy, evaluated through score improvements and Fleiss κ for interobserver agreement. Reliability in the Meary angle measurement was also assessed.

Results: FA specialists demonstrated consistently high baseline scores. Following the intervention, OT and FD groups exhibited significant improvements in both diagnostic and referral scores. Fleiss κ increased from 0.463 to 0.700 for OT diagnosis, and from 0.439 to 0.723 for referral. Fleiss κ values for FD improved from 0.352 to 0.546 for diagnosis and from 0.071 to 0.608 for referral. Face-to-face/webinar training outperformed the PDF format, yielding higher scores and agreement rates. Interobserver reliability for the Meary angle was excellent (intraclass correlation coefficient = 0.988).

Conclusion: Structured educational interventions significantly enhanced clinicians' ability to diagnose and appropriately refer patients with Charcot foot. Face-to-face instruction proved more effective than self-directed formats.

Level of evidence: Level III, quasi-experimental pre-post study.

Background: Achilles tendon rupture (ATR) is among the most common foot and ankle injuries, with a rising incidence of up to 50 per 100 000 persons. We sought to investigate the medicolegal characteristics associated with ATR.

Methods: Westlaw Precision, an online, legal database from across the United States, was queried for all jury verdicts and settlements pertaining to "malpractice" and "Achilles" tendon rupture from 1980 to 2024. Data extracted included date and state of claim filing, patient and defendant demographics, jury verdict, monetary payments, basis of litigation, and listed patient complications.

Results: A total of 50 of 236 claims were included in this analysis. A defendant verdict was reached in 82% of claims. The average indemnity payment was $431 405. Orthopaedic surgeons were named in 44% of claims. Nearly one-half of claims were levied due to a delayed or missed diagnosis (24%) or insufficient informed consent (18%). Subsequent surgery was the most frequent complication of the alleged negligence (18%); however, patient death occurred in 14% of claims as well. Patient disagreement with the treatment strategy was seen in 18% of claims.

Conclusion: Achilles tendon rupture is an infrequent source of medicolegal burden within foot and ankle treatment. Such legal action most commonly arises from diagnostic delays, insufficient informed consent, and patient disagreement with the treatment strategy. Early recognition, comprehensive counseling on management options and risks, and shared decision making are essential strategies to reduce litigation risk and improve patient outcomes.

Level of evidence: Level IV, case series / retrospective database review without comparison group.

Background: Cartilage lesions with concomitant subchondral plate damage are challenging pathologies for foot and ankle surgeons. Recent clinical reports suggest that recombinant human bone morphogenetic protein-2 (rhBMP-2) can restore structural integrity of the subchondral plate and promote osseous healing, potentially improving outcomes for cartilage repair procedures. This study seeks to evaluate the complication rate and patient-reported outcomes of rhBMP-2-augmented repair for ankle osteochondral lesions with subchondral involvement.

Methods: Patients who received surgical repair with rhBMP-2, extracellular matrix (ECM), and bone marrow aspirate concentrate (BMAC) for the treatment of an ankle osteochondral defect with an associated subchondral damage between January 2023 and September 2024 were retrospectively chart reviewed. Twenty-one patients who fit the criteria were included. All patients completed Patient-Reported Outcomes Measurement Information System (PROMIS) surveys preoperatively and at minimum 1 year postoperatively. Clinical outcomes, postoperative complications, and revision surgery were recorded.

Results: The average time from surgery to postoperative survey follow-up was 17.9 (range, 12.0-27.3) months. Average cartilage lesion size was 88.4 (range, 36.0-120) mm². Significant pre- to postoperative improvement in Physical Function, Pain Interference, and Pain Intensity were observed among the patient cohort. Physical Function score increased by an average of 10.4 points (P < .05). Pain Interference improved by an average of 10.4 points (P < .05). Pain Intensity decreased by an average of 8.6 points (P < .05). Global Physical Health increased by an average of 8.4 points (P < .05). Global Mental Health and Depression did not change significantly. Observed changes exceeded commonly cited PROMIS minimal clinically important differences for lower-extremity populations. The complication rate was low, with only 2 patients (9.5%) reporting persistent pain requiring a return to the operating room for revision surgery.

Conclusion: Our results suggest that this procedure is an effective treatment with a significant improvement in clinical outcomes and a low complication rate.

Level of evidence: Level IV, case series.