The latest medical research on Foot & Ankle Orthopaedics

The research magnet gathers the latest research from around the web, based on your specialty area. Below you will find a sample of some of the most recent articles from reputable medical journals about foot & ankle orthopaedics gathered by our medical AI research bot.

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Risk Factors for Failure of Conservative Management of Insertional Achilles Tendinosis.

Foot and Ankle International

While many patients benefit from nonoperative treatment of insertional Achilles tendinopathy (IAT), some elect for surgical debridement and reconstruction. The purpose of this study is to determine the relationship of patient demographic characteristics, comorbidity profiles, and radiological parameters with failure of conservative management of IAT.

A retrospective chart review was performed to identify patients who received either surgical or nonsurgical treatment of IAT at an academic institution from September 2015 to June 2019 (N = 226). Demographic and comorbidity data, and the presence and magnitude of relevant radiological parameters were collected and compared between the surgically (n = 48) and nonsurgically (n = 178) treated groups.

No significant differences could be detected between groups regarding demographic factors or previous procedures. The surgery group was significantly more likely to have evidence of Haglund's deformity on clinical exam (83% vs 69%, P = .005), lower SF-12 physical scores (25.5 vs 35.5, P < .001), higher VAS pain scores (6.3 vs 5.3, P = .033), any mental illness (33% vs 20%, P = .044), and depression (27% vs 12%, P = .012).

Patients who received surgery for IAT were significantly more likely to have evidence of Haglund's deformity on clinical exam, depression, higher VAS pain scores, and lower SF-12 physical scores. Both patients and surgeons should be aware of the higher rates of failure of conservative treatment in these patients.

Level III.

Foot Osteomyelitis Location and Rates of Primary or Secondary Major Amputations in Patients With Diabetes.

Foot and Ankle International

Diabetic foot osteomyelitis (DFO) often leads to amputations in the lower extremity. Data on the influence of the initial anatomical DFO localization on ultimate major amputation are limited.

In this retrospective analysis, 583 amputation episodes in 344 patients (78 females, 266 males) were analyzed. All received a form of amputation in combination with antibiotic therapy. A multivariate logistic regression analysis with the primary outcome "major amputation" defined as an amputation above the ankle joint was performed. The association of risk factors including location of DFO, coronary artery disease, peripheral artery disease, neuropathy, nephropathy, and Charcot neuro-osteoarthropathy was analyzed.

Among 583 episodes, DFO was located in the forefoot in 512 (87.8%), in the midfoot in 43 (7.4%), and in the hindfoot in 28 episodes (4.8%). Overall, 53 of 63 (84.1%) major amputations were performed because of DFO in the setting of peripheral artery disease as primary indication. Overall, limb loss occurred in 6.1% (31/512) of forefoot, 20.9% (9/43) of midfoot, and 46.4% (13/28) of hindfoot DFO. Among these, 22 (41.5%) were performed as the primary treatment, whereas 31 (58.5%) followed previously failed minor amputations. Among this latter group of secondary major amputations, the DFO was localized to the forefoot in 23 of 583 (3.9%), the midfoot in 4 of 583 (0.7%) and the hindfoot in 4 of 583 (0.7%). In multivariate logistic regression analysis, initial hindfoot localization was a significant factor (P < .05), whereas peripheral artery disease, smoking, and a midfoot DFO were not found to be risk factors.

In our retrospective series, the frequency of limb loss in DFO increased with more proximal initial foot DFO lesions, with almost half of patients losing their limbs with a hindfoot DFO.

Level IV, retrospective cohort study.

Functional Outcomes of Autologous Matrix-Related Chondrogenesis to Treat Large Osteochondral Lesions of the Talus.

Foot and Ankle International

Osteochondral lesions of the talus (OLT) treatment is widely debated when the lesion size exceeds 150 mm2. The aim of this study was to assess functional outcome and satisfaction rates of the autologous matrix-related chondrogenesis (AMIC) technique and compare the outcomes for OLTs larger than 150 mm2 that were classified as primary, primary with local tumor-related OLT, or revision cases.

A total of 77 patients who were operated by AMIC were included. The average age of the population was 39.6 years. The mean body mass index (BMI) was 27.2. Smoker rate was 28.5% of the population. Forty-two patients were primary cases, 14 patients had primary with local tumor-related OLT, and 18 patients were revision cases. Overall and subgroup functional outcomes were evaluated by visual analog scale (VAS) and Foot and Ankle Disability Index (FADI) scores. Satisfaction rates were queried, and failures were recorded.

After a median follow-up of 32 months, the score improvement for primary, primary with local tumor-related, and revision group were for VAS, 5.4 ± 0.4, 5.6 ± 0.7, and 3.6 ± 0.8, and for FADI, 46.5 ± 3.8, 45.3 ±6.5, and 26.6 ± 6.7, respectively (P < .001). Intergroup comparison showed greater improvement for the primary OLT group when compared to the revision group (P < .001). The failure rates for the primary, primary with local tumor-related, and revision group were 4.8%, 11.8%, and 38.9%, respectively.

AMIC procedure provides good functional outcome and satisfactory rates in patients with primary and primary with local tumor-related OLT larger than 150 mm2, but in revision cases, the AMIC success rate was not encouraging as all had advanced OLT operative interventions.

Level III, therapeutic retrospective study.

Midterm Prospective Evaluation of Structural Allograft Transplantation for Osteochondral Lesions of the Talar Shoulder.

Foot and Ankle International

In cases of large osteochondral lesions of the talus (OLTs), fresh structural or bulk osteochondral allograft transplantation has yielded favorable outcomes in several retrospective and few prospective case series. The purpose of this study was to prospectively evaluate patients who received fresh structural allograft transplantation of the talar shoulder.

A prospective evaluation of patients who received a fresh structural allograft of an OLT was performed. Preoperative imaging included magnetic resonance imaging (MRI) and/or computed tomography (CT) with plain radiographs. The following patient-reported outcomes questionnaires were administered preoperatively and yearly after surgery: 36-Item Short-Form Health Survey (SF-36), visual analog scale (VAS) for pain, and the Short Musculoskeletal Functional Assessment (SMFA). Preoperative and postoperative imaging were evaluated for allograft assimilation, evidence of arthritic changes, or functional range of motion abnormalities.

Thirty-one patients with a mean age of 41.4 years (±14.1, range 18-69) underwent structural fresh osteochondral allograft transplantation to the talar shoulder and were included in this study. The mean follow-up was 56.2 months (±36.1, range 24-142). The majority of patients were female (n=17, 54.8%), reported some history of prior ankle trauma (n=21, 67.7%), and underwent prior ankle surgery (n=23, 74.2%). The mean lesion size on CT scan was 1879 mm3 (n = 27) compared to the mean lesion size of 3877 mm3 (n = 21) on MRI. There was a significant improvement in the mean preoperative VAS score (P < .0001), SF-36 score (P < .0005), SMFA bother index (P < .0015), and the SMFA function index (P < .0001) at final follow-up. A total of 15 (48.4%) patients underwent an additional surgery following their osteochondral allograft transplant, most commonly arthroscopic debridement or removal of hardware, performed at an average of 25.2 (±13.0) from their index procedure. There was one failure that required a total ankle replacement. The overall graft survival rate was 96.8%.

Fresh, structural allograft transplantation resulted in significant improvement in patient-reported postoperative pain and function in patients suffering from OLTs. The graft survival rate was 96.8% at a mean of 56.2 months follow-up, with half of patients requiring a second procedure.

Level IV, prospective case series.

A Case-Control Study of 3D vs 2D Weightbearing CT Measurements of the M1-M2 Intermetatarsal Angle in Hallux Valgus.

Foot and Ankle International

Weightbearing computed tomography (WBCT) 3-dimensional measurements may be reliable in assessing hallux valgus (HV). The objective of this study was to compare 2D and 3D WBCT measurements of the M1-M2 intermetatarsal angle (IMA) in patients with HV and in healthy controls. We hypothesized that 2D and 3D IMA measurements would correlate and have similar reliability in both HV and controls.

Retrospective multicenter comparative study included WBCT scans from 83 feet (41 HV, 42 controls). IMA was measured on digitally reconstructed radiographs (DRR-IMA). 3D angle (3D-IMA) and its projection on the weightbearing plane (2D-IMA) were calculated from 3D coordinates of the first and second metatarsals. Intraobserver reliability and intermethod correlations were calculated using intraclass correlation coefficients (ICCs).

Intraobserver reliability was very strong for DRR-IMA (0.95) and 3D-IMA (0.99). Intermethod correlation between the 3 modalities in HV patients ranged from moderate (DRR vs 2D, 0.48; DRR vs 3D, 0.48) to very strong (2D vs 3D, 0.91). Similarly, intermethod correlation in the control group ranged from moderate (DRR vs 2D, 0.56; DRR vs 3D, 0.60) to very strong (2D vs 3D, 0.92).

Measurements for IMA are similar using DRR, 3D and 2D projected angles, with very strong intraobserver reliability and moderate to very strong intermethod correlations. This is the first head-to-head comparison between these measurement modalities in HV. Further investigations are warranted before formulating guidelines for the clinical use of 3D angles.

Level III, case-control study.

Coronal Plane Rotation of the Medial Column in Hallux Valgus: A Retrospective Case-Control Study.

Foot and Ankle International

We previously reported an increase in pronation of the first metatarsal (M1) head relative to the ground in hallux valgus (HV) patients compared to controls. Still, the origin and location of this hyperpronation along the medial column is unknown. Recent studies showed that presence of progressive collapsing foot deformities (PCFDs), which is a condition frequently associated with HV, can strongly influence the medial column coronal plane alignment. The objective of this study was to assess the coronal rotation of the medial column bones in HV feet, HV feet with radiologic markers of PCFD, and controls. We hypothesized that hyperpronation in HV will originate from a combination of M1 intrinsic torsion and first tarsometatarsal joint malposition.

The same cohort of 36 HV and 20 controls matched on age, gender, and body mass index was used. Previously, a validation of the measurements was carried out through a cadaveric study. Using these metrics, we assessed the coronal plane rotation of the navicular, medial cuneiform, and the M1 at its base and head with respect to the ground using weightbearing CT images. We measured the Meary angle and the calcaneal moment arm in our 36 HV subjects. We subdivided our cohort into an HV group and a potential PCFD HV group according to these measurements. Comparisons on medial column bones coronal rotation were performed between HV, PCFD HV, and control groups.

Twenty-two HV cases were included in the HV group and 14 in the PCFD HV group. Both groups presented an increase in pronation of the first metatarsal head relative to the ground when compared to the control group (P < .001). Comparing HV and controls showed an 8.3 degrees increase in pronation of M1 intrinsic torsion (P < .001) and a 4.7 degrees pronated malposition of the first tarsometatarsal joint (P = .02) in HV. A 9.7 degrees supinated malposition of the first naviculocuneiform joint (P < .001) was also observed in HV. Comparing PCFD HV and controls showed a significant increase in pronation of the navicular (respectively, 17.2 ± 5.4 and 12.3 ± 3.4 degrees, P = .007) and a 5.5 degrees increase in pronation of M1 intrinsic torsion (P = .02) in PCFD HV, without malposition of the first tarsometatarsal and naviculocuneiform joints.

Hyperpronation of the M1 head relative to the ground originated from both increases in pronation of M1 intrinsic torsion and first tarsometatarsal joint malposition in HV, although partially counterbalanced by a supinated malposition of the first naviculocuneiform joint. On the other hand, PCFD HV patients showed a generalized pronated position throughout the medial column from the navicular to the M1 head and may be related to the midfoot and hindfoot deformities frequently present in PCFD.

Level III, retrospective comparative study.

Reliability of Fifth Metatarsal Base Fracture Classifications and Current Management.

Foot and Ankle International

Classification of fifth metatarsal base fractures has been a source of confusion since originally described by Jones in 1902. Zone classifications have been described but never evaluated for reliability. The most recent classification, metaphyseal vs meta-diaphyseal, may be unknown to many surgeons. The purpose of this study was to evaluate reliability of American Orthopaedic Foot & Ankle Society (AOFAS) members classifying fifth metatarsal base fractures and current management of these fractures.

A survey was emailed to AOFAS members including radiographs of 18 fifth metatarsal base fractures. Demographic information was collected in addition to evaluation of the radiographs. Interrater reliability was assessed for each measurement: presence of Jones fracture, zone classification, and metaphyseal vs metaphyseal-diaphyseal, using Fleiss kappa. After 3 weeks, a second email was sent to the members asking to retake the survey to evaluate intrarater reliability. Respondents were asked which region is a Jones fracture, which classification is used, if symptomatic zone 2 and 3 fractures are treated similarly, and what fractures are operative in healthy symptomatic acute fractures.

A total of 223 AOFAS members, with a median time in practice of 12 years (range 0-50), completed the initial survey. Eighty members (36%) repeated the survey for intrarater comparison. Interrater reliability was moderate for Jones and zone classification but substantial for the 2-zone metaphyseal/meta-diaphyseal classification. The median intrarater kappa was 0.78, 0.75, and 0.78 for Jones, zone, and metaphyseal/meta-diaphyseal respectively. Seventy percent of respondents treat zones 2 and 3 similarly, and approximately 60% consider an acute symptomatic fracture identified as Jones, zone 2 or zone 3 operative.

A 2-zone system may be the best available classification for fifth metatarsal base fractures given high interrater reliability and 70% of AOFAS members treat zones 2 and 3 in similar fashion.

Level III, diagnostic study.

Minimal Clinically Important Differences of PROMIS PF in Ankle Fracture Patients.

Foot and Ankle International

Evaluating the minimal clinically important differences (MCIDs) in patient-reported outcome scores is essential for use of clinical outcomes data. The purpose of the current study was to calculate MCID of Patient Reported Outcome Information System Physical Function (PROMIS PF) scores for ankle fracture patients.

All patients who underwent operative fixation for ankle fractures at a single level 1 trauma center were identified by Current Procedural Terminology code. PROMIS PF scores were collected. Patients had to complete an anchor question at 2 time points postoperatively to be included in this study. Anchor-based and distribution-based MCIDs were calculated.

A total of 331 patients were included in the distribution-based analysis, and 195 patients were included in the anchor-based analysis. Mean age was 45.3 years (SD 17.5), and 59.4% of participants were female. MCID for PROMIS PF scores was 5.05 in the distribution-based method and 5.43 in the anchor-based method.

This study identified MCID values based on 2 time points postoperatively for PROMIS PF scores in the ankle fracture population. Both methods of MCID calculation resulted in equivalent MCIDs. This can be used to identify patients outside the normal preoperative and postoperative norms and may help to make clinically relevant practice decisions.

Level I, diagnostic study, testing of previously developed diagnostic measure on consecutive patients with reference standard applied.

Coronal plane Calcaneal-Talar Orientation in Varus Ankle Osteoarthritis.

Foot and Ankle International

We do not yet fully understand how the subtalar joint position is related to the varus osteoarthritic ankle joint. The purposes of this study were (1) to investigate the coronal orientation of the calcaneus relative to the talus according to the ankle osteoarthritis stage, talar tilt (TT), and (2) to determine if there is TT threshold at which apparent subtalar compensation begins to fade.

We retrospectively reviewed 132 ankles that underwent weightbearing computed tomography (WBCT) for varus ankle osteoarthritis. The TT, subtalar inclination angle (SIA), and calcaneal inclination angle (CIA) were measured using WBCT. Ankles were divided into 5 groups according to Takakura stage and 2 groups according to the apparent compensation status of the subtalar joint and compared the index of the inclination of the subtalar joint relative to the ankle (SIA) or the index of the inclination of the calcaneus relative to the ankle (CIA). Additionally, we explored the relationship between SIA or CIA and the TT.

Apparent subtalar compensation (SIA and CIA) was significantly lower in Takakura stages 3b and 4. The SIA and CIA significantly differed according to the apparent compensation status (P < .001 and P = .030, respectively). The CIA of the noncompensated group varied widely, whereas the SIA was relatively constant. Furthermore, TT was greater than 9.5, which indicated a high probability of a noncompensated heel (sensitivity, 92.6%; specificity, 89.7%).

The position of the calcaneus appears compensatory with coronal plane orientation in varus ankle osteoarthritis when the TT is ≤9.5 degrees.

Level III, retrospective case control study.

Regional Anesthesia Decreases Inpatient But Not Outpatient Opioid Demand in Ankle and Distal Tibia Fracture Surgery.

Foot and Ankle International

Regional anesthesia (RA) is commonly used in ankle and distal tibia fracture surgery. However, the pragmatic effects of this treatment on inpatient and outpatient opioid demand are unclear. The hypothesis was that RA would decrease inpatient opioid consumption and have little effect on outpatient demand in patients undergoing ankle and distal tibia fracture surgery compared with patients not receiving RA.

All patients aged 18 years and older undergoing ankle and distal tibia fracture surgery at a single institution between July 2013 and July 2018 were included in this study (n = 1310). Inpatient opioid consumption (0-72 hours postoperatively) and outpatient opioid prescribing (1 month preoperatively to 90 days postoperatively) were recorded in oxycodone 5-mg equivalents (OEs). Adjusted models were used to evaluate the impact of RA versus no RA on inpatient and outpatient opioid demand.

Patients without RA had higher rates of high-energy mechanism of injury, additional injuries, open fractures, and additional surgery compared with patients with RA. Adjusted models demonstrated decreased inpatient opioid consumption in patients with RA (12.1 estimated OEs without RA vs 8.8 OEs with RA from 0 to 24 hours postoperatively, P < .001) but no significant difference after that time (9.7 vs 10.4 from 24 to 48 hours postoperatively, and 9.5 vs 8.5 from 48 to 72 hours postoperatively). Estimated cumulative outpatient opioid demand was significantly increased in patients receiving RA at all time points (112.5 OEs without RA vs 137.3 with RA from 1 month preoperatively to 2 weeks, 125.6 vs 155.5 OEs to 6 weeks, and 134.6 vs 163.3 OEs to 90 days, all P values for RA <.001).

In ankle and distal tibia fracture surgery, RA was associated with decreased early inpatient opioid demand but significantly increased outpatient demand after adjusting for baseline patient and treatment characteristics. This study encourages the use of RA to decrease inpatient opioid use, although there was a worrisome increase in outpatient opioid demand.

Level III: Retrospective, therapeutic cohort study.

Anterior Capsule Reconstruction in the Setting of PVNS.

Foot and Ankle International

Pigmented villonodular synovitis (PVNS) is a benign proliferative disease affecting tendon sheaths and synovial tissue. Pigmented villonodular synovitis in the foot and ankle has a high rate of recurrence, which can be destructive if incompletely removed. This case series analyzes functional outcomes after PVNS operative resection with an anterior ankle capsular reconstruction, using a novel technique.

Three patients with PVNS underwent surgery between 2010 and 2020. The operative technique involved a posterior, midline approach for PVNS resection of the affected ankle joint, followed by a standard anterior approach for capsular excision. Subsequent anterior capsular reconstruction was performed with a regenerative tissue matrix and a bioresorbable anchoring system. Preoperative and postoperative range of motion for the ankle and subtalar joints, visual analog scale (VAS) for pain, and return to daily activities was assessed along with appropriate radiographs and magnetic resonance imaging (MRI) imaging.

All 3 surgeries had a mean follow-up period of 52.3 (range, 4-123) months and resulted in successful recovery as assessed by the VAS and self-reported activity. Preoperative ankle dorsiflexion and plantarflexion along with subtalar inversion and eversion range of motion were all normal. Postoperative ankle motion and subtalar motion were not statistically different. No complications or recurrence of PVNS was observed.

Further investigation is warranted to better understand the clinical outcomes of this technique designed to successfully eliminate PVNS recurrence.

IV- Retrospective case series.

Avoiding Fifth Metatarsal Intramedullary Screw Head Cuboid Impingement: A Weightbearing Computed Tomography Anatomic Study.

Foot and Ankle International

Multiple case reports of fifth metatarsal (MT) intramedullary fixation highlight symptomatic hardware with screw head impingement on the cuboid. We developed a fifth MT intramedullary screw trajectory model using weightbearing computed tomography data. The goal was to assess for cuboid impingement with simulated intramedullary screw position.

For 20 weightbearing foot computed tomographs (CTs), an automated tool was used to simulate fifth MT screw fixation in the ideal trajectory down the shaft and with a 7-mm screw head. (1) The closest distance from the simulated ideal trajectory to the cuboid in 3 dimensions was measured. A measurement less than 3.5 mm (the radius of the screw head) indicated screw head impingement on the cuboid if not countersunk into the metatarsal. (2) In 3 dimensions, a simulated screw head was then advanced from the proximal tip of the metatarsal distally into the metatarsal until it was entirely avoiding the cuboid.

In this model, 95% (19/20) of the patients would have cuboid impingement if the screw was not countersunk. The average ideal pin start distance was 0.15 mm (SD 2.4 mm) inside the cuboid. In this cohort, the screw head would have to be countersunk an average of 8.1 mm (SD 2.7 mm) relative to the proximal tip of the metatarsal to avoid cuboid impingement. For all cases, the simulated fluoroscopic oblique view was a reliable indicator of cuboid impingement, demonstrating visible overlapping of the screw with the cuboid. The overlap resolved on the oblique foot view once the screw was sufficiently countersunk, confirmed on 3-dimensional imaging.

The ideal guidewire placement for fifth MT intramedullary fixation is directly against the cuboid. Approximately 95% of patients would have cuboid impingement if the screw is not countersunk. The oblique fluoroscopic view of the foot is a reliable assessment of screw head impingement on the cuboid.

Level III, retrospective study.