Foot & ankle specialist最新文献

Background: The effects of preoperative depression following ankle fracture surgery remains unknown. The purpose of this study is to investigate the relationship between preoperative depression and outcomes following ankle fracture surgery.

Methods: This retrospective study used the Truven MarketScan database to identify patients who underwent ankle fracture surgery from January 2009 to December 2018. Patients with and without a diagnosis of preoperative depression were identified based on International Classification of Diseases (ICD) codes. Chi-squared and multivariate analyses were performed to determine the association between preoperative depression and postoperative complications following ankle fracture surgery. Results. In total, 107,897 patients were identified for analysis, 13,981 of whom were diagnosed with depression (13%). Preoperative depression was associated with the increased odds for postoperative infection (odds ratio [OR]: 1.33, confidence interval [CI]: 1.20-1.46), wound complications (OR: 1.13, CI: 1.00-1.28), pain-related postoperative emergency department visits (OR: 1.58, CI: 1.30-19.1), 30-day and 90-day readmissions (OR: 1.08, CI: 1.03-1.21 and OR: 1.13, CI: 1.07-1.18), sepsis (OR: 1.39, CI: 1.12-1.72), and postoperative development of complex regional pain syndrome (OR: 1.46, CI: 1.18-1.81).

Conclusion: Preoperative depression is associated with increased complications following ankle fracture surgery. Further studies are warranted to investigate the degree to which depression is a modifiable risk factor.

Level of evidence: 3.

Introduction: There is little information on the value of using single photon emission computerized tomography-computed tomography (SPECT-CT) in non-arthritic and non-neoplastic conditions of the foot and ankle (F&A). The vast majority of studies have investigated the role of SPECT-CT in degenerative conditions, bony pathology, and neoplastic conditions. The diagnostic value of SPECT-CT in purely non-arthritic and non-neoplastic conditions, in the absence of other conclusive radiological findings, is yet to be clarified. The aim of this study was to evaluate the value of SPECT-CT in a cohort of patients with complex F&A pathology, in whom diagnostic uncertainty existed after conventional imaging techniques, and to assess its added value in routine clinical practice.

Methodology: A retrospective analysis of 297 SPECT-CTs from 2010 to 2017 found 18 SPECT-CTs (age = 16-56 years) performed for non-arthritic F&A pathology. Changes in diagnosis, management, and clinical outcome scores were recorded before and after SPECT-CT imaging.

Results: The results demonstrated that the provisional diagnosis was different from the SPECT-CT diagnosis in 10 (56%) out of the 18 patients and led to a modified treatment plan, which was successful in 8 (80%) out of the 10 patients. The post-intervention Manchester Oxford Foot Questionnaire (MOX-FQ) and Visual Analogue Scale (VAS) score improved from 76 ± 18 to 58 ± 24 (P = .02), and from 72 ± 17 to 49 ± 32 (P = .01), respectively. The SPECT-CT scan was useful in confirming the provisional diagnosis in the remaining 8 patients where a diagnostic uncertainty existed after conventional imaging techniques. Overall, a total of 15 out of 18 patients (83%) showed an improvement in their symptoms after management led by SPECT-CT diagnosis.

Conclusion: Our study highlights the added value of SPECT-CT in patients presenting with non-arthritic and non-neoplastic F&A conditions in which there is diagnostic uncertainty after conventional imaging. In 80% of cases, a change in management driven by the SPECT-CT findings led to a successful outcome. We have found SPECT-CT to be a useful investigative modality in assessing these complex F&A cases.

Levels of evidence: Level IV.

Background.: This study aims to investigate the effect of hypoalbuminemia on the rates of 30-day complication, readmission, and reoperation following total ankle arthroplasty (TAA).

Methods.: The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2007 to 2019 to identify 710 TAA patients. Patients were then stratified into normal (n = 673) or low (n = 37) albumin groups. Demographics, medical comorbidities, concomitant procedures, hospital length of stay, and 30-day complication, readmission, and reoperation rates were compared between groups. Preoperative serum albumin level was also used as a continuous variable when analyzing postoperative outcomes.

Results.: The overall cohort was predominantly male (51.5%), and the mean age was 65.02 (range, 45-87) years. We found there to be no statistically significant difference in demographics between cohorts. However, hypoalbuminemia patients were significantly more likely to use long-term steroids for a chronic condition (normal = 6.1%, low = 18.9%; P = .009). Additionally, there was no difference in 30-day complication (normal = 3.0%, low = 0.0%; P = .618), readmission (normal = 2.4%, low = 0.0%; P = .632), and reoperation (normal = 1.0%, low = 0.0%; P = 1.000) rates between groups.

Conclusion.: The results of this study show that malnourished patients are not at an increased risk of 30-day complication, readmission, or reoperation following TAA despite having a worse preoperative comorbidity profile.

Level of evidence: Level III, Retrospective cohort study.

Purpose: Several risk factors for lower extremity amputation in diabetic patients have been identified; however, late presentation has been poorly investigated. Very few studies looked at the impact of such risk factor. As none has investigated the link between admission to amputation and late presentation in this population, we investigated such association.

Methods: The study is a retrospective comparative cohort of continuous series of patients admitted for amputation related to diabetic foot ulcer (DFU) as a first treatment. A late presentation was defined as a period of 3 weeks or more from the onset of the ulcer.

Results: Forty-six patients admitted for amputation and all wounds were infected and located on the plantar forefoot in 32 cases (69.5%), on the toes in 10 cases (21.7%), and in the heel area in 4 cases (8.8%). The mean duration to admission was 5.2 ±1.8 weeks (range 4-10 weeks). Late presentation was recorded in 42 (91.3%) patients.

Conclusion: This study demonstrates that amputation due to DFU is highly associated with late presentation. Educational campaigns targeting patient and first-line health care providers and highlighting the urgency of diabetic ulcers are needed to impact this major modifiable risk factor.

Levels of evidence: Therapeutic, Level III: Retrospective Comparative.

Background: Postoperative outcomes may be affected by the patient's preoperative morbidity. It is hypothesized that patient's pain catastrophization prior to foot and ankle surgery may affect their patient-reported outcomes. Methods: This study prospectively assessed a consecutive cohort of 46 patients undergoing foot and ankle reconstruction to describe the relationship between Pain Catastrophizing Scale (PCS) and patient-reported outcomes measured by 12-item Short Form Health Survey and Foot and Ankle Outcome Score (FAOS).

Results: The 1-year postoperative FAOS pain, activities of daily living, and quality of life scores correlated significantly with all baseline PCS subcategories. We found that the mental domain of the SF-12 had a statistically significant correlation with the rumination and helplessness PCS subcategories.

Conclusion: This study showed a significant association between a high preoperative PCS and a worse 1-year FAOS. As such, catastrophization could be screened for and potentially treated preoperatively to improve patient-reported outcomes in elective foot and ankle surgery.

Level of evidence: Therapeutic, Level III Evidence.

Background: The use of a valid and reliable outcome scoring system is crucial for evaluating the result of different treatment interventions. The aims of this study were to translate and culturally adapt the American Orthopaedic Foot and Ankle Society (AOFAS) midfoot scoring system into the Persian language and assess its validity and reliability.

Method: In total, 57 patients with midfoot injuries were enrolled. Forward-backward translation and cultural adaptation methods were used to develop the Persian version of AOFAS midfoot scoring system. Reliability and internal consistency were assessed using intraclass correlation coefficient (ICC) and Cronbach's alpha. The discriminant and convergent validities of the scoring system were assessed using the total score of the mental and physical component of SF-36.

Results: The mean age of the participants was 46.2 ± 16.3 years. The intra-observer reliability of the totals core of the Persian version of AOFAS midfoot scoring system was 0.96 (confidence interval [CI]: 0.92-0.97) and the inter-observer reliability of the scoring system was 0.90 (CI: 0.86-0.95). The Persian version of AOFAS midfoot scoring system had acceptable convergence with physical component scoring system of SF-36 and its subscales (0.57); moreover, it had acceptable discriminant validity with the mental component of SF-36 and its subscales (0.36).

Conclusion: The Persian version of AOFAS midfoot is a reliable and valid instrument and could be used by Persian language clinicians and researchers.

Level of clinical evidence: 3.

Background: Exposure to a comprehensive breadth and volume of surgical cases is a fundamental component of orthopaedic education, though standardization of case exposures across residency programs is limited to a small amount of required case minimums. Significant variability in exposure to subspecialty cases, such as foot and ankle surgeries, can create distinctly different residency experiences.

Methods: Accreditation Council for Graduate Medical Education (ACGME) surgical case logs from 2014 to 2019 for leg/ankle and foot/toes were examined following the 2013 implementation of case minimums. Average surgical case volume across subcategories and the average volume of different residency percentiles were analyzed to assess variability.

Results: The mean total volume of case exposure for graduating orthopaedic residents has increased significantly since 2014 for both leg/ankle cases (28.6%) and foot/toes (27.8%), though totals were still down compared with when ACGME reporting began in 2007. Arthrodesis exposures have increased significantly for leg/ankle (69.2%) and foot/toes (93.8%) cases since 2014, and ankle arthroscopy has increased 20.7%. Disparities in total cases between 10th and 90th percentile programs have shown a nonsignificant decrease over time, with significant differences between leg/ankle arthrodesis (8-fold), leg/ankle arthroscopy (13-fold), and foot/toe arthrodesis (3.5-fold) in 2019.

Conclusion: The mean volume of foot and ankle case exposures among graduating residents has continued to rise since the implementation of case minimums in 2013 but disparities in volume are present, most notably concerning arthrodesis and arthroscopy. Recognition and future attention toward addressing this variability can be meaningful in promoting a more comprehensive, standardized orthopaedics education.

Level of evidence: Level III: Retrospective comparative study.

Case: Avascular necrosis (AVN) of the talus in a 45-year-old female following subchondroplasty with calcium phosphate bone filler for treatment of anterolateral and posteromedial talar dome bone marrow lesions (BMLs). The patient subsequently presented as consultation, 18 months postoperatively, with AVN of the talus. After failing conservative management, the patient underwent a total ankle arthroplasty at 46 months after subchondroplasty with resolution of pain.

Conclusion: There are few studies that have reported on the safety of subchondroplasty of the talus. Given the tenuous blood supply to the talar body and poor patient outcomes associated with AVN, caution should be taken before extrapolating the generally positive results of subchondroplasty in the knee.

Level of evidence: Level IV.

Background: Revision neurectomy may be approached with either a dorsal or a plantar incision. Although a plantar approach is more commonly described, few studies have investigated outcomes following a dorsal revision neuroma excision. In this study, we performed a case series on a group of patients who underwent revision neuroma excision through a dorsal approach and reported complications and outcomes using validated patient-reported outcome measures (PROMs).

Methods: This retrospective case series included 10 patients who underwent a dorsal-approach revision neuroma excision and had preoperative and minimum 1-year postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores. Complications including neuroma recurrence and continued unresolved pain were obtained from the electronic medical record. Preoperative and postoperative PROMIS scores were compared to assess improvement in PROMs.

Results: There were significant improvements in the PROMIS pain interference (P = .026), pain intensity (P = .008), and global physical health (P = .017) domains. One patient experienced recurrence of their neuroma 4 years after surgery.

Conclusion: This case series provides preliminary data indicating that revision neurectomy using a dorsal approach leads to satisfactory outcomes in pain-related PROMs. Further research with comparative study designs is necessary to determine if one approach is superior to the other.

Levels of evidence: Level IV: Retrospective.

Background: It is well known that flatfeet are associated with a higher incidence of lower limb injuries in different populations. Thus, we examine how Pilates exercise training affects static balance and ankle and knee proprioception in females with and without flexible flatfeet. Study Design. Case series; Level of evidence.

Methods: This quasi-experimental study involves 91 healthy 18- to 25-year-old female university students. The Navicular Drop Test was used to diagnose flatfeet. Pilates included core strength, balance, and flexibility exercises for 16 weeks. Static balance was assessed using the sharpened Romberg test and ankle and knee joint proprioception were measured using joint position reproduction tests. The Wilcoxon test indicated within-group pre-post improvements in static balance, and ankle and knee joint proprioception in the Pilates and the healthy control group (P < .05).

Results: The between-group comparisons at post-test showed significant differences for joint position reproduction test of the dorsiflexion (P < .05, η² = 0.10) and the plantarflexion (P < 0.05, η² = 0.08) in favor of the healthy controls group. Joint proprioception of ankle and knee was positively correlated with increasing static balance in the healthy control group.

Conclusion: The results showed that Pilates has the potential to improve static balance, and ankle and knee proprioception. However, it did not improve postural control and proprioception in individuals with flatfeet. Our findings advise combining Pilates with other interventions to develop flexible flatfeet in females.

Levels of evidence: Level I.