Foot & ankle international最新文献

Background: An understanding of the anatomical development of the fifth metatarsal apophysis is essential for clinical assessment and management of subadult patients presenting with lateral foot pain or oedema that worsens with activity. Despite the common occurrence of subadult lateral foot pain, current understanding of apophyseal development is constrained because of the reliance on plain radiography in the literature, resulting in simplistic descriptions of development. To overcome these limitations, this study aimed to investigate the development of the fifth metatarsal apophysis using 3-dimensional computed tomography analysis, to provide novel morphologic descriptions and normative sex-specific age tables for each developmental stage in a contemporary Australian subadult population.

Methods: Development and fusion status of the apophysis was scored using a novel 5-stage scoring system on 295 multi-slice computed tomography scans (158 females, 137 males; 0-15 years of age) and 258 lateral, anteroposterior, and oblique radiographs (120 females, 138 males; 0-7 years of age) from the Queensland Children's Hospital.

Results: The apophysis commenced ossification as early as 7 years for females and 8 years for males, initially appearing as a thin fleck of bone that elongated to form a crescent shape, with the proximal aspect being wider and extending more medially compared with the distal aspect. Apophyseal fusion demonstrated significant sexual dimorphism with fusion commencing at a mean age of 10.09 years for females and 12 years for males, with the earliest age of complete fusion observed at 9 years for females and 12 years for males.

Conclusion: This cross-sectional study provides contemporary descriptive reference data for staging development of the fifth metatarsal apophysis and an updated account of its morphology. These observations may assist radiographic interpretation in adolescents; however, the study was not designed to evaluate diagnostic accuracy or clinical outcomes. Further clinical validation is needed before using these data to guide diagnosis or to reduce misclassification of fractures versus apophysitis.

Background: Transfibular total ankle arthroplasty (TAA) necessitates a fibular osteotomy followed by reduction and fixation after component implantation. Although this approach offers advantages such as adjusting fibular length and alignment, there is concern about the potential complication of fibular nonunion. The purpose of this study is to determine the incidence of radiographic nonunion of the fibular osteotomy in a large single-surgeon series.

Methods: Retrospective review was performed of all transfibular TAA performed by a single surgeon from 2012 to 2022, and patients with minimum 2-year radiographic follow-up were included. Fibular osteotomy fixation was achieved with a lateral locked plate. Weightbearing ankle radiographs were analyzed at 3, 6, 12, and 24 months postoperatively for evidence of healing based on mature bridging bone across the osteotomy. Secondary analyses at 3 and 6 months were performed based on patient age (<55 vs 55 ≥ years old), history of diabetes, and smoking status.

Results: A total of 406 ankles (380 patients) with a mean age of 60 years (range, 23-85) were included in this analysis. Incomplete healing of the fibular osteotomy was observed in 16.3% of ankles at 3 months, 5.9% at 6 months, and 1.0% at 12 and 24 months. Rates of union at 3 and 6 months were not statistically different based on patient age, history of diabetes, or smoking status (all P > .05). Four (1.0%) nonunions were observed in total: 2 cases were symptomatic and healed following revision fixation with bone grafting.

Conclusion: In this large series of consecutive transfibular TAA, most patients had healed their fibular osteotomy by 3 months. There was no association between osteotomy healing and patient age, smoking status, or diabetes at 3 and 6 months postoperatively, and the overall incidence of fibular nonunion was 1%. These results should be reassuring to surgeons concerned about this potential complication when considering transfibular approach for TAA.

Level of evidence: Level IV, case series.

Background: The purpose of this study was to assess the subtalar joint's kinematics in in the frontal plane (inversion-eversion) using 3D weightbearing cone beam computed tomography by measuring both translational and angular range of motion.

Methods: In this cohort study, weightbearing cone beam computed tomography images were acquired of 41 subjects under weightbearing stress in 20 degrees inversion and 10 degrees eversion tilt, achieved with hard plastic wedges. The ankle was in neutral position, and the sole of the foot was entirely on the wedge. Interobserver and intraobserver reliability were assessed using intraclass correlation coefficients.

Results: All the measured numeric range of motion values in the normal subtalar joint's bony structures were small; however, values were larger in eversion than in inversion. Translational range of motion in the middle facet (1.4 mm) is smaller than in the anterior facet (4.9 mm). Reliability was good to excellent for most parameters; however, several showed poor reliability-particularly interobserver agreement for inversion measures of the middle-facet angle/translation and select talocrural metrics (midpoint/medial joint-space width, joint angle).

Conclusion: This study defines the subtalar joint's translational and angular range of motion in the frontal plane (inversion-eversion) under weightbearing stress in normal subtalar joint's bony structures. The applicability of the method should be investigated in different patient groups.

Background: Achilles tendon repairs and reconstructions have historically been associated with high infection rates because of poor vascularity. However, newer surgical infection control strategies can reduce morbidity associated with infection. We hypothesized that with appropriate treatment and management of these infections, patients can reach high levels of physical function with minimal pain comparable to those without postoperative infection.

Methods: Chart review was conducted for all patients who underwent Achilles tendon surgery at our institution between 2011 and 2020. We identified patients who experienced postoperative wound infection requiring return to the operating room. Clinical outcomes, antibiotic type, and duration were recorded. Patient-Reported Outcomes Measurement Information System (PROMIS) surveys were sent to all patients at a minimum of 1 year postoperatively.

Results: A total of 1148 patients underwent Achilles tendon surgery, of whom 23 patients (2.0%) experienced a postoperative wound infection requiring surgical intervention. Ten patients who presented from outside institutions with an existing Achilles infection were included for management/outcome descriptions but excluded from risk-factor incidence analyses because of missing index-procedure details, increasing the overall cohort to 33. Among 604 acute repairs, 8 patients (1.32%) developed infections, compared with 15 of 544 chronic tendinopathy cases (2.75%). In chronic cases, graft use was associated with higher infection rate (8.96% vs 0.73%, P < .0001). Patients with postoperative infection demonstrated significantly worse in physical function (46.9 vs 51.6, P = .01) and pain interference (52.1 vs 48.1, P = .03) PROMIS scores. No other PROMIS domains showed significant difference between the 2 cohorts. By 18 months postoperatively, 26 of the 33 patients (78.78%) could toe-walk on the affected side with little to no difficulty.

Conclusion: Early, aggressive management yields good recovery after postoperative infection; however, residual deficits in function and pain persist compared with uninfected peers in our cohort at 2-year follow-up.

Background: Foot and ankle offset (FAO) is a semiautomatic weightbearing computed tomography (WBCT) measurement that assesses the 3-dimensional (3D) relationship between the ankle joint center and the foot tripod, offering a global view of hindfoot alignment (HA). Because FAO does not isolate subtalar alignment, we introduce and assess the reliability of subtalar joint offset (SJO), a 3D WBCT measure of SJ alignment relative to the foot tripod.

Methods: We conducted a retrospective study on 204 feet categorized as neutral (n = 30), valgus (n = 107), or varus (n = 67) based on FAO values (-0.6% < neutral < 5.2%). SJO was calculated by identifying the position of the SJ calcaneal middle facet in relation to the foot tripod using WBCT software (Talas, Cubevue; CurvebeamAI). Intra- and interobserver intraclass correlation coefficients (ICCs) were calculated. We calculated the SJO-FAO difference in millimeters on the same reference plane and analyzed correlations by group (Bonferroni-adjusted α = 0.006).

Results: ICC values were excellent (intraobserver: 0.98; interobserver: 0.92). FAO significantly differed across groups: neutral (2.52 ± 2.38), valgus (10.68 ± 4.03), and varus (-8.9 ± 6.92) (P < .001). SJO also varied significantly: neutral (15.3 ± 2.07), valgus (20.85 ± 2.78), and varus (10.32 ± 3.08) (P < .001). The SJO-FAO difference was smallest in valgus (10.16 ± 2.01), intermediate in neutral (12.88 ± 2.67), and largest in varus (19.08 ± 5.12) (P < .001). A moderate correlation was found between FAO and SJO in the varus and valgus groups (ρ = 0.68, r² = 0.51; and ρ = 0.68, r² = 0.57), and low in the neutral group (ρ = 0.47, r² = 0.36) (all P < .001).

Conclusion: SJO is a reliable WBCT metric for distinguishing subtalar alignment across valgus, neutral, and varus HA. Prospective, multicenter studies should test whether the SJO-FAO difference quantifies subtalar contribution and informs realignment surgery.

Background: 3D printing is a cost-effective manufacturing approach that offers several advantages for health care delivery, including rapid prototyping, precise customization to patient anatomy and user specifications, and the capability to produce implants directly at the point of care. The purpose of this study was to test whether 3D-printed carbon fiber-reinforced polyetheretherketone (CF-PEEK) one-third tubular plates are statistically equivalent, within prespecified margins, to stainless steel plates in simulated early weightbearing and torsion.

Methods: Carbon fiber-reinforced polyetheretherketone one-third tubular plates were designed and printed using Fused Deposition Modeling printers by study authors. These were compared to traditionally manufactured plates using 4-point bend tests. A cadaveric biomechanical comparison between fractures stabilized using 3D-printed plates and traditional manufactured plates was performed. Matched-pairs specimens underwent axial cyclic loading and torsional load to failure.

Results: Ten matched paired specimens underwent mechanical testing. All specimens survived 100 000 cycles loaded to 875 N. Torque at failure did not significantly differ between groups (P = .14). During torsional load to failure, all 10 specimens (100%) with the traditional plate failed because of screw pullout. Five specimens (50%) with the 3D plate failed because of screw pullout and 5 (50%) failed because of plate fracture. Fifteen plates (five 3D, five 3D post autoclave, 5 traditional) underwent 4-point bending test. Stiffness was significantly lower in the 3D plates (P < .0001). The coefficient of variation was 0.06 for the 3D-printed plates and 0.01 for the traditional manufactured plates, demonstrating high consistency within groups.

Conclusion: In conclusion, this cadaveric study found that nonsterilized CF-PEEK plates demonstrated statistically equivalent displacement and torque at failure to stainless steel plates. However, they exhibited reduced stiffness and a higher incidence of plate fracture. Additionally, autoclave sterilization had a significant impact on the mechanical properties of the CF-PEEK plates. These findings underscore the need for additional biomechanical and clinical studies to assess the performance of 3D-printed implants and to refine sterilization protocols.

Clinical relevance: These results suggest that constructs using 3D-printed CF-PEEK plates can perform statistically equivalently (within prespecified margins) to stainless steel constructs in simulated early weightbearing and torsion, despite different material properties. The impact of sterilization, however, must be considered, and alternatives to autoclaving are recommended.

Background: The role of postoperative tibial sesamoid position (TSP) in hallux valgus (HV) recurrence remains controversial, and studies on its impact after third-generation minimally invasive HV surgery are limited. This study analyzed the association between postoperative TSP and outcomes after minimally invasive transverse distal metatarsal osteotomy (MITO) for HV correction.

Methods: This retrospective cohort study included 118 patients who underwent MITO between July 2018 and August 2022 with ≥24 months of follow-up. Patients were grouped by 1-month postoperative TSP based on Hardy and Clapham classification (grades I-III: normal; grades IV-VII: outlier). Clinical outcomes were assessed using visual analog scale pain scores, Foot and Ankle Outcome Scores, and Medical Outcomes Study Short Form Health Survey-36 physical component summary scores. Radiologic evaluation included hallux valgus angle (HVA), first-to-second intermetatarsal angle (1-2 IMA), and TSP measurements. Recurrence and complications were also analyzed.

Results: This study analyzed 165 feet (normal: 122 feet; outlier: 43 feet) with a mean follow-up of 35.6 months (range, 24-70 months). The outlier group showed consistently greater HVA (43.8 degrees vs 32.7 degrees preoperatively; 8.7 degrees vs 4.8 degrees at 1 month; 12.8 degrees vs 5.1 degrees at last follow-up), 1-2 IMA (15.6 degrees vs 13.0 degrees preoperatively; 5.7 degrees vs 3.7 degrees at 1 month; 6.6 degrees vs 4.5 degrees at last follow-up), and TSP (7 vs 6 preoperatively; 4 vs 2 at 1 month; 5 vs 2 at last follow-up) at all time points (all P < .001), with greater HVA increase from 1 month postoperatively to last follow-up (P < .001). Functional scores improved similarly in both groups. On multivariable analysis, an outlier TSP at 1 month independently predicted recurrence (adjusted odds ratio 13.24, 95% CI 3.40-51.58), with good discrimination (area under the curve 0.838). Recurrence (P < .001) and reoperation rates for symptomatic recurrence (P = .017) were significantly higher in the outlier group.

Conclusion: Postoperative TSP on anteroposterior standing radiographs at 1 month after surgery was associated with HV recurrence after MITO surgery. Precise correction of TSP may be essential to reduce the likelihood of HV recurrence.

Background: Although prior ankle or subtalar arthrodesis is thought to affect outcomes at adjacent joints, previous studies have not distinguished between successful and failed prior fusions. This study examines whether prior successful vs failed ipsilateral arthrodesis influences nonunion risk in subsequent ankle or subtalar fusion. The primary objective of this study is to examine nonunion rates after subtalar and ankle arthrodesis in patients with and without prior ipsilateral arthrodesis, and vice versa.

Methods: A retrospective study using the TriNetX Research Network compared nonunion rates in patients who underwent subtalar (ST) arthrodesis with (ankle-ST) or without (ST-only) prior ankle arthrodesis. Patients were stratified by whether the prior arthrodesis was successful (no nonunion diagnosis/revision) or failed (nonunion requiring revision Ankle-ST patients were stratified by successful or failed prior ankle arthrodesis. A secondary analysis evaluated ankle arthrodesis in patients with (ST-ankle) or without (ankle-only) prior subtalar arthrodesis, similarly stratified. Propensity score matching (1:1) adjusted for age, sex, body mass index (BMI), and comorbidities. The primary outcome is nonunion rates.

Results: 144 patients were in the successful ankle-ST cohort and 12,635 in the ST-only cohort. After propensity score matching, successful ankle-ST patients had no difference in nonunion rates (16.7% vs 16.0%, P = .873). However, patients with failed prior ankle arthrodesis had a 3-fold higher risk of subtalar nonunion compared to those with successful ankle fusion (risk ratio [RR] 3.0, 95% CI 1.79-5.02). Furthermore, 109 patients were in the successful ST-Ankle group and 6,801 in the ankle-only group. After matching, there was no difference in rate of nonunion (11.1% vs 19.4%, P = .089) between the successful ST-ankle and the ankle-only groups. Conversely, patients with failed prior subtalar arthrodesis had a 2.4-fold higher risk of ankle nonunion compared to those with successful subtalar fusion (RR 2.4, 95% CI 1.30-4.42).

Conclusion: Our analysis of the TriNetX Research Network database suggests that when the primary ankle or subtalar arthrodesis is successful, performing a subsequent adjacent fusion does not significantly increase the risk of nonunion compared with an isolated fusion. However, failed prior arthrodesis substantially increases nonunion risk, highlighting the importance of distinguishing between successful and failed prior procedures in clinical decision-making.