Orthopaedic Surgeons Foot Research Articles

Combined Randomised and Observational Study of Surgery for Type B Ankle Fracture Treatment (CROSSBAT) Minimum 5 Year Follow-Up

Category: Trauma; Ankle Introduction/Purpose: Isolated Type B ankle fractures are common. The study (CROSSBAT: Combined Randomised and Observational Study of Surgery for Type B Ankle Fracture Treatment) demonstrated that surgical management was not superior to non-surgical management for the treatment of 44-B1 ankle (fibula) fractures with minimal talar shift at one-year post-injury. The current study presents longer term results of that cohort with a minimum 5-year follow-up. It aims to determine whether surgical management confers improved outcomes for participants with isolated AO type 44-B1 distal fibula fractures when compared with non-surgical management at minimum 5 years post- injury. Methods: A multi-centre, randomised controlled trial with an observational cohort was conducted. Participants were recruited from 22 hospitals across Australia and New Zealand. Participants consenting to follow-up but not randomisation formed the observational cohort. SURGICAL GROUP: Fracture fixation using a plate and screws. Post-operatively, ankles were splinted and participants were non-weight-bearing for 2 weeks, then weight-bearing was allowed; NON-SURGICAL GROUP: Ankles were splinted and participants were allowed to weight-bear. OUTCOMES: All participants were followed with a minimum 5-year follow-up. Primary outcomes were the American Academy of Orthopaedic Surgeons Foot and Ankle Outcomes Questionnaire (FAOQ) and the physical component score (PCS) of SF-12v2 general-health survey at 12 months. The randomised and observational cohorts were analysed separately. Results: Between August 2010 to October 2013 160 people were randomised (80 surgical and 80 non- surgical). 276 formed the observational cohort (19 surgical and 257 non-surgical). At minimum 5 year follow-up, 75 (47%) and 103 (37%) in the randomised and observational cohort respectively were contactable. Surgery was not superior for ankle function score or SF-12v2 compared with non-surgical group in the randomised or observational cohorts. Conclusion: Surgical management was not superior to non-surgical management in patients who sustained a distal fibula fracture with minimal talar shift.

EARLY WEIGHT BEARING MOBILIZATION AFTER SURGICAL FIXATION OF UNSTABLE ANKLE FRACTURES– PROSPECTIVE STUDY

Objective:The purpose of the study is to clarify outcomes of early weight bearing in lower extremity fractures treated operatively and advantage of Immediate-Early weight bearing over LWB mobilization Prospective study A total of 136 skeleta Design: Materials and methods: lly mature patients underwent ankle surgery, 33 of which were allowed immediate weightbearing as tolerated (IWBAT) in the acute postoperative period was taken into study At the scheduled follow-up, patients had wound assessment, radiogra Outcome Measures: phic analysis of fracture reduction maintenance and healing, clinical fracture healing evaluation, and complications requiring further surgery. After 6 months the patients were individually assessed using a Modied American Academy of Orthopaedic Surgeons Foot and Ankle Scale (MAAOSFS) This study Results : demonstrates that IWBAT in a certain subset of patients with stable osteosynthesis following an ankle fracture is a safe alternative to a period of protected weight-bearing. Earlier weight-bearing is associated with earlier return to full weight bearing without a reduction in functional outcome scores. IWBAT in a certain subset of patients with stable osteosynthesi Conclusions: s following an ankle fracture is a safe alternative to a period of protected weight-bearing. Earlier weight-bearing has been associated with better mobility, shorter hospital stays, and earlier return to work. Potential candidates for IWBAT are patients with closed ankle fractures, without syndesmotic disruption, and with no involvement of the tibial plafond and in whom stable xation has been achieved. Conict of Interests The authors declare that there is no conict of interests regarding the publication of this paper

Minimum 5-Year Follow-up Results: CROSSBAT (Combined Randomised and Observational Study of Surgery vs No Surgery for Type B Ankle Fracture Treatment).

Isolated Weber B, AO (Association for the Study of Internal Fixation) type 44B ankle fractures with no fracture to the medial side are the most common type of ankle fracture and may be treated with internal fixation or without surgery.This study aimed to determine if surgery is superior to nonsurgical management for the treatment of these fractures after a minimum 5-year follow-up. Design: A pragmatic, multicenter, single-masked, randomized controlled trial with minimum 5-year follow-up. Setting/participants/interventions: Participants between 18 and 65 years with AO type 44B ankle fracture and minimal talar shift were recruited from 22 hospitals in Australia and New Zealand. Participants willing to be randomized were randomly allocated to undergo surgical fixation followed by mobilization in a walking boot for 6 weeks. Those treated nonsurgically were managed in a walking boot for 6 weeks. Outcome assessors were masked for the treatment allocation. Primary outcomes: Patient-reported ankle function using the American Academy of Orthopaedic Surgeons Foot and Ankle Outcomes Questionnaire (FAOQ) and the physical component summary (PCS) of the SF-12v2 General Health Survey at 12 months postinjury and at minimum 5 years post injury. Primary analysis was intention-to-treat. Of the 160 (80 surgical, 80 nonoperative) randomized patients included in the CROSSBAT analysis, 77 (40 surgical, 37 nonoperative) were followed up for repeat analysis at minimum 5-year follow-up (mean 7.3 years, range 5.1-8.9). This cohort demonstrated that surgery was not associated with clinically or statistically significant differences compared to nonoperative management for the FAOQ (51.7 vs 49.6; mean difference 2.1, 95% CI -2.1 to 6.2, P = .95), or the PCS (51.5 vs 49.1; mean difference 2.3, 95% CI -2.0 to 6.7, P = .54). The surgical cohort had a higher rate of any adverse events (odds ratio 3.7, 95% CI 1.2-11.6, P = .04). The results of this study suggest that surgical management is not superior to nonsurgical management in type B ankle (fibula) fractures with minimal talar shift over a 5-year period and is associated with increased adverse events. Level II, randomized clinical trial.

Donor-site Morbidity following Microvascular Fibular Transfer for Head and Neck Reconstruction

BACKGROUND: Continuous refinement in head and neck reconstruction requires a thorough evaluation of donor-site morbidity of established workhorse flaps. Regardless of the favoritism bestowed on the free fibular flap (FFF) for head and neck reconstruction by most microsurgeons, the donor-site morbidity associated with harvesting remains a controversial and concerning issue. In fact, the perioperative donor-site complication rate following FFF harvest ranges between 2% to 38%. The objective of this study is to analyze surgical and postoperative factors that contribute to donor-site morbidity in patients undergoing FFF transfer for mandibular and/or maxillary reconstruction of oncologic defects. METHODS: We conducted a prospective single-institutional investigation to analyze complications and assess their effect on the postoperative status of the ankle, great toe, and gait in 53 patients who underwent reconstruction of maxillary and/or mandibular defects with the FFF. We used the American Academy of Orthopaedic Surgeons foot and ankle questionnaire (AAOS-FAOQ), X-ray of ankles, and clinical examination (pain, paresthesia, claw toe deformity, and range of motion) to evaluate postoperative outcomes one, three, and six months after surgery. RESULTS: Forty-six males (86.8%) and seven females (13.2%) were finally included. The mean age was 50.18 years (range, 22-75). The mean tourniquet time was 74.25 minutes. The mean length of the segment of fibula harvested was 12.85 ± 1.1 cm, while the residual mean distal and proximal fibula segment length were 6.6 cm (range, 6-8) and 6.7 cm (range, 6-8) respectively. The mean size of the skin paddle harvested was 53.2 cm2 (range, 36-64 cm2). Flap failure secondary to venous congestion was seen in 2 cases. The most common acute donor site complications recorded were edema of the ipsilateral foot (11.30%) and delayed wound healing (9.4%). Additional complications reported included partial graft loss (7.5%) and wound infection (7.5%). Three of the four grafts that were partially lost, had signs of infection (75%). Spontaneous recovery was observed in the 3 partial graft loss cases (75%) whereas 1 patient (25%) required an additional STSG. Long-term claw toe deformity was observed in 1 patient (1.8%) who had required excision of the flexus hallucis longus. Nerve alterations were present in the form of paresthesia (39.6%) and superficial peroneal nerve sensory loss (18.9%). The overall rate of perioperative donor site complications was 35.8%. Significant improvement in the average AAOS-FAOQ score was observed at 6-months when compared to 1-month results (p<.001). Dorsiflexion (p=0.923) and plantarflexion (p=0.913) did not significantly improve at different time points. Complications did not affect range of motion for dorsiflexion (p=0.759) or plantarflexion (p=0.254) at 6-months. A larger residual fibular stump (≥8cm) did not significantly affect postoperative ROM for dorsiflexion (p=0.232) or plantarflexion at 6-months. A large skin paddle area resulted in an increase in incidence of complications. (p <.001). CONCLUSION: Although FFF is associated with a high complication rate and postoperative reduction in lower limb performance, these findings do not challenge the reliability of this versatile flap. A larger flap’s skin paddle increases the rate of donor-site complications. Future studies focusing on refinement of harvest technique are anticipated.

Screw Fixation of the Posterior Malleolus Fragment in Ankle Fracture

Category:Ankle; TraumaIntroduction/Purpose:This study aimed to evaluate the outcomes of ankle fractures with posterior malleolus fragments (PMFs)involving <25% of the articular surface treated with or without screw fixation.Methods:Among patients with ankle fractures and PMFs who underwent surgery between March 2014 and February2017, 62 with type 1 PMFs involving <25% of the articular surface were included. Of these 62 patients, 32 underwent screw fixation for PMFs and lateral and/or medial malleolar fracture fixation (group A) and 30 underwent internal fixation for malleolar fractures without screw fixation for PMFs (group B). Ankle joint alignment and fracture healing were measured using plain radiography and computed tomography (CT). Clinical outcomes were determined using the American Academy of Orthopaedic Surgeons Foot and Ankle Questionnaire, Short Form-36, and American Orthopaedic Foot & Ankle Society Scale.Results:Nonunion was not noted in either group. However, we detected union with a step-off of 2 mm or more in2 cases from group B. With regard to ankle joint alignment, 1 case in group A and 3 cases in group B showed mild asymmetry of the medial and lateral clear spaces on CT at 12 months. Clinical outcomes at 6 and 12 months after surgery were better in group A than in group B.Conclusion:Screw fixation of PMFs was effective for fracture healing and maintaining ankle alignment. Additionally, it improved short-term clinical outcomes, which we believe was due to stabilization of ankle fractures with PMFs involving <25% of the articular surface.

Omitting Routine Radiography of Traumatic Ankle Fractures After Initial 2-Week Follow-up Does Not Affect Outcomes: The WARRIOR Trial: A Multicenter Randomized Controlled Trial.

The clinical consequences of routine follow-up radiographs for patients with ankle fracture are unclear, and their usefulness is disputed. The purpose of the present study was to determine if routine radiographs made at weeks 6 and 12 can be omitted without compromising clinical outcomes. This multicenter randomized controlled trial with a noninferiority design included 246 patients with an ankle fracture, 153 (62%) of whom received operative treatment. At 6 and 12 weeks of follow-up, patients in the routine-care group (n = 128) received routine radiographs whereas patients in the reduced-imaging group (n = 118) did not. The primary outcome was the Olerud-Molander Ankle Score (OMAS). Secondary outcomes were the American Academy of Orthopaedic Surgeons (AAOS) foot and ankle questionnaire, health-related quality of life (HRQoL) as measured with the EuroQol-5 Dimensions-3 Levels (EQ-5D-3L) and Short Form-36 (SF-36), complications, pain, health perception, self-perceived recovery, the number of radiographs, and the indications for radiographs to be made. The outcomes were assessed at baseline and at 6, 12, 26, and 52 weeks of follow-up. Data were analyzed with use of mixed models. Reduced imaging was noninferior compared with routine care in terms of OMAS scores (difference [β], -0.9; 95% confidence interval [CI], -6.2 to 4.4). AAOS scores, HRQoL, pain, health perception, and self-perceived recovery did not differ between groups. Patients in the reduced-imaging group received a median of 4 radiographs, whereas those in the routine-care group received a median of 5 radiographs (p < 0.05). The rates of complications were similar (27.1% [32 of 118] in the reduced-imaging group, compared with 22.7% [29 of 128] in the routine-care group, p = 0.42). The types of complications were also similar. Implementation of a reduced-imaging protocol following an ankle fracture has no measurable negative effects on functional outcome, pain, and complication rates during the first year of follow-up. The number of follow-up radiographs can be reduced by implementing this protocol. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Functional Outcomes of Isolated Infrasyndesmotic Fibula Fractures.

Background:Ankle fractures are among the most common injuries encountered by orthopedic surgeons, with an incidence ranging from 71 to 187 per 100 000 people. Few studies have reliably investigated injuries involving isolated fractures of the distal fibula below the level of the ankle syndesmosis. Therefore, this study details on the patient-reported outcomes of nonoperatively managed isolated infrasyndesmotic fibula (ISF) fractures with a minimum 3-year follow-up.Methods:A retrospective population-based cohort study was undertaken across all emergency departments serving a major urban population. Among 159 consecutive patients meeting inclusion criteria, 108 agreed to participate. Clinical information, functional outcomes, and radiographic measurements were collected from electronic medical records and 3 validated outcome measures: the American Academy of Orthopaedic Surgeons (AAOS) Foot & Ankle Scale (FAS), the AAOS Shoe-Comfort Scale (SCS), and a general questionnaire.Results:An incidence of 22 ISF fractures per 100 000 people/year was found with FAS (91.2 ± 12.9) and SCS scores (76.8 ± 27.7), similar to reported population norms. Approximately 40% of patients (n = 43) reported continuing symptoms including pain (81.8%), stiffness (68.1%), and/or instability (39.0%). Less than 13% (n = 14) reported “severe” disabilities, and no patients required operative intervention within the follow-up period. Less-favorable outcomes were reported among work-related injuries, female patients, and “avulsion-type” fractures less than 10 mm in height (P < .01). No relationships were identified between age, degree of articular-incongruity, fracture-displacement, and self-reported outcomes.Conclusions:The majority of patients with nonoperatively managed ISF fractures reported good-to-excellent early functional outcomes. Less-favorable outcomes were reported among work-related injuries, female patients, and “avulsion-type” fractures.Level of Evidence:Level III, comparative series.

Outcomes of Salvage Arthrodesis and Arthroplasty for Failed Osteochondral Allograft Transplantation of the Ankle.

Osteochondral allograft (OCA) transplantation is a useful treatment for posttraumatic ankle arthritis in young patients, but failure rates are high and reoperations are not uncommon. The aim of this study was to evaluate the outcomes of failed ankle OCA transplantation converted to ankle arthrodesis (AA) or total ankle arthroplasty (TAA). We evaluated 24 patients who underwent salvage procedures (13 AA and 11 TAA) after primary failed ankle OCA transplantation. Reoperations were assessed. Failure of the salvage procedure was defined as an additional surgery that required a revision AA/TAA or amputation. Evaluation among nonfailing ankles included the American Academy of Orthopaedic Surgeons Foot and Ankle Module (AAOS-FAM), pain, and satisfaction. In the salvage AA cohort, 3 patients were classified as failures (2 revision AA and 1 amputation). The 10 nonfailing patients had a mean follow-up of 7.4 years. Eighty-eight percent were satisfied with the procedure, but 63% reported continued problems with their ankle (eg, pain, swelling, stiffness). Mean pain level was 1.9 and AAOS-FAM core score was 83±13. In the salvage TAA cohort, 2 patients were classified as failures (both revision TAA). The 9 nonfailing patients had a mean follow-up of 3.8 years. Fifty percent were satisfied with the procedure, but 40% reported continued problems with their ankle. The mean pain level was 1.3, and the median AAOS-FAM core score was 82±26. Revision and reoperation rates for salvage procedures following failed OCA transplantation of the ankle are higher compared to published data for primary AA and TAA procedures. However, we believe OCA transplantation can serve as an interim procedure for younger patients with advanced ankle joint disease who may not be ideal candidates for primary AA or TAA at the time of initial presentation. Level IV, case series.

Fibular nails for open and closed ankle fractures: Results from a non-designer level I major trauma centre.

To evaluate the outcome of a fibular nail in the treatment of open and closed unstable ankle fractures in a non-designer centre. In a retrospective cohort study, a total of 39 ankle fractures (14 open and 25 closed) treated with a locking fibular nail were evaluated between 2012 and 2015 in a non-designer level I major trauma centre. Post-operative radiographs were analysed to assess the quality of reduction (McLennan and Ungersma marking system), fracture union and complications. Three patient reported outcome scores (Olerud and Molander score (OMAS), American Association of Orthopaedic Surgeons (AAOS) foot and ankle score and 12-Item Short Form Survey (SF-12)) were collected to obtain an overall measure of the patient's physical and mental outcome. The adequacy of reduction data was available for 38 of 39 cases; 33 (87%) achieved good, 3 (8%) fair and 2 (5%) poor ratings, based on the McLennan and Ungersma marking system. Thirty-five (12 open and 23 closed) patients were available for initial follow-up. Five (14.3%) of 35 had documented complications (2 of 12 in the open cohort and 3 of 23 in the closed cohort). All fibular fractures treated with the fibular nail went on to unite. Twenty-three (66%) of 35 patients were available at 1-year follow-up for measurement of objective outcome. The combined mean OMAS for both groups was 53.7 (0-85) with statistically better results (59.5 (25-85) vs. 37.3 (0-75)) in favour of the closed versus open injuries, respectively. The mean AAOS score was also statistically better for the closed group than the open, 70.3 (30-95) versus 46.6 (20-77), respectively. The mean SF-12 score (physical component) was 40 (21.6-52.4) in the closed group versus 36.1 (19.4-51.5) in the open group; the mean mental component was 42.5 (26.6-54.3) in the closed group versus 38.8 (28.4-60.5) in the open group, these however were not statistically different. Fibular nails are an effective alternative for the treatment for both closed and open unstable ankle fractures with soft tissue compromise.

Efficacy of foot orthoses as nonoperative treatment for hallux valgus: A 2-year follow-up study

BackgroundThe purpose of this study was to clarify the 2-year clinical and radiological outcomes of nonoperative treatment using foot orthosis for hallux valgus patients. MethodsPatients who underwent nonoperative treatment using foot orthosis were surveyed prospectively. Foot orthoses were made by one certified orthotist using the standardized method. Pain and quality of life were evaluated using subjective and objective assessment measures at 3, 6, 12, 18, and 24 months. Furthermore, radiological outcomes, patient satisfaction, and adherence to treatment were surveyed. ResultsA total of 53 patients (50 women and 3 men; median age, 63 years) were included for analysis. The pain visual analogue scale score significantly decreased over time, with the lowest score observed at 12 months. The treatment effect was maintained over 24 months (median score, 52, 21, and 27 points at baseline, 12 months, and 24 months, respectively; P < .001). The Japanese Society for Surgery of the Foot hallux scale, American Academy of Orthopaedic Surgeons Foot and Ankle Scale, and 36-Item Short-Form Health Survey bodily pain subscale also improved, although the treatment effects were maximal at 6 months and decreased thereafter. At 24 months, 43 (81%) patients continued to use the orthosis, with the median visual analogue scale score for patient satisfaction of 76 points. The hallux valgus angle and intermetatarsal angle did not change during the 24-month period. ConclusionNonoperative treatment using foot orthoses decreased pain in patients with hallux valgus. The effect of treatment was maintained up to 2 years with a relatively high degree of patient satisfaction. However, treating physicians should inform patients to set realistic expectations and be aware that a limited degree of pain reduction is expected.

Osteochondral Allograft Transplantation for Osteochondral Lesions of the Talus: Midterm Follow-up.

Fresh osteochondral allograft (OCA) transplantation represents a biologic restoration technique as an alternative treatment option for larger osteochondral lesions of the talus (OLT). The purpose of this study was to evaluate midterm outcomes after OCA transplantation for the treatment of OLT. Nineteen patients (20 ankles) received partial unipolar OCA transplant for symptomatic OLT between January 1998 and October 2014. The mean age was 34.7 years, and 53% were male. The average graft size was 3.8 cm2. All patients had a minimum follow-up of 2 years. Outcomes included the American Academy of Orthopaedic Surgeons Foot and Ankle Module (AAOS-FAM), the Olerud-Molander Ankle Score (OMAS), and pain and satisfaction questionnaires. Failure of OCA was defined as conversion to arthrodesis or revision OCA transplantation. Five of 20 ankles (25%) required further surgery, of which 3 (5%) were considered OCA failures (2 arthrodesis and 1 OCA revision). The mean time to failure was 3.5 (range, 0.9 to 6.7) years. Survivorship was 88.7% at 5 years and 81.3% at 10 years. The median follow-up of the 17 patients with grafts in situ was 9.7 years. The mean OMAS improved significantly from 40 points preoperatively to 71 points postoperatively ( P < .05; range, 5 to 55). The mean postoperative AAOS-FAM core score was 81.5 ± 15 (range, 40.5 to 96.6). Fifteen of 17 patients responded to follow-up questions regarding their ankle; 14 patients reported less pain and better function, and 13 patients were satisfied with the results of the procedure. Our study of midterm results after OCA transplantations showed that this procedure was a reasonable treatment option for large OLT. Level IV, case series.

Early Clinical Outcomes of Triplanar Modified Lapidus Arthrodesis with Immediate Weight Bearing

Category: Bunion Introduction/Purpose: There are numerous corrective procedures for hallux valgus deformity. The majority of procedures prioritize correction in the transverse plane based on anteroposterior (AP) radiographs. Long-term results demonstrate high recurrence rates ranging from 8-78% with various metatarsal osteotomy techniques. Recent evidence suggests that hallux valgus is a multi-planar deformity with significant contributions from the sagittal and frontal planes. Correction of hallux valgus at the first tarsometatarsal joint (modified Lapidus) offers a powerful method to restore anatomic alignment in all three planes and correct hallux valgus at the apex of the deformity. The purpose of this study is to investigate early clinical and radiographic outcomes and complications of triplanar tarsometatarsal (TMT) arthrodesis with immediate weight-bearing. Methods: After receiving IRB approval, charts and radiographs were retrospectively reviewed for 37 patients (30 female, age 54.8 years) undergoing triplanar tarsometatarsal (TMT) arthrodesis for hallux valgus deformity correction at our institution between June 2016 and June 2017. All patients were allowed immediate weight-bearing as tolerated in a boot walker. Radiographic imaging at 4 months and 12 months was compared to pre-operative imaging. Clinical outcomes were evaluated using the American Academy of Orthopaedic Surgeons Foot and Ankle questionnaire (AAOS FAQ), Quality of Life 12 (QOL-12), and the patient-reported outcomes measurement information system 10 (PROMIS 10). Demographics included age, gender, body mass index, and medical comorbidities. The time in days to weight-bearing, wearing athletic shoes, and return to full activity were noted. Any complications were recorded. For statistical analysis, t-tests were performed for continuous variables and chi-square tests were performed for categorical variables using JMP 11.0.0 (SAS Institute Inc., Cary, NC). Results: Although improvements were noted in the AAOS FAQ and PROMIS 10 at 3 and 6 months post-operative, these results were not significantly different compared to baseline scores (Table 1). From the time of procedure, average time to weight-bearing was 2.75 ± 7.2 days. Patients returned to wearing athletic shoes an average of 48.3 ± 12.1 days after the procedure. Return to full activity without restrictions was 130.9 ± 37.0 days from surgery. Radiographic results demonstrated significant improvement in IMA and HVA at final follow-up (p &lt; 0.001). 35 patients (94.6%) demonstrated evidence of radiographic union by final follow-up. Regarding complications, one patient (2.7%) required hardware removal for soft-tissue irritation, and there were three cases (8.1%) of hardware failure that did not require re-operation. Conclusion: In this study, early clinical and radiographic outcomes of triplanar tarsometatarsal corrective arthrodesis (modified Lapidus) with immediate weight-bearing were promising with low complication rates. Patients were able to return to normal shoe wear approximately 7 weeks after the procedure and return to full activity a little more than 4 months after surgery. Radiographic results demonstrated high union rates, low recurrence rates, and significant improvements in HVA and IMA at final follow-up. Longer follow-up is necessary to determine the long-term radiographic and clinical outcomes of triplanar tarsometatarsal arthrodesis to correct hallux valgus deformity.

Functional bracing treatment for stable type B ankle fractures

BackgroundIn general, stable type B ankle fractures are treated conservatively with cast immobilization or a walking boot during six weeks. Some disadvantages of casting are joint stiffness, muscle wasting and lack of comfort. This study was designed to evaluate whether functional treatment with a removable brace is a safe and more comfortable alternative. Material and methodsRandomized controlled trial. In the period March 2013 - May 2015, 44 patients visiting the emergency department due to a stable type B ankle fracture were included. During the first week both groups received a splint. After one week the patients were randomized: one group received a cast, the other a removable brace. For outcome Olerud & Molander Ankle Score, Visual Analogue Score for comfort and pain, American Academy of Orthopaedic Surgeons (AAOS) Foot and Ankle score questionnaire, EuroQol-5D and range of motion were used. Results44 patients participated (21 cast, 23 brace). There were no differences in baseline characteristics. After 6 weeks, VAS for comfort (cast vs brace; 5.74 vs 7.21; p = 0.02) and total range of motion (40° vs 49°; p = 0.00) showed significant differences in favour of the brace. VAS pain (3.15 vs 2.05; p = 0.16), OMA-score (51.75 vs 61.32; p = 0.22) en EuroQoL-5D (7.26 vs 6.74; p = 0.33) did not show significant differences. Week 52 showed no significant differences at OMA-score (89.29 vs 96.18; p = 0.16), EuroQoL-5D (6.00 vs 5.35; p = 0.15), VAS pain (1.07 vs 0.82; p = 0.69) and AAOS score (91.71 vs 96.06; p = 0.21). No complications occurred in both groups. ConclusionFunctional bracing showed significant differences for the VAS comfort score and range of motion at 6 weeks compared to casting. After a year no significant differences were found. Treatment with a brace is a safe and more comfortable option for stable type B ankle fractures.

Validity of the Hispanic version of the American Academy of Orthopaedic Surgeons Foot and Ankle Outcomes Questionnaire in patients with traumatic foot and ankle injuries.

Background:Hispanics represent the largest minority group in the United States and are projected to represent 29% of the US population by 2060. Enrolling Hispanic patients in clinical outcome trials is critical to study a representative sample of the general population. Lack of translated and validated survey tools has been identified as a major barrier to enrolling Spanish speaking patients. The purpose of this validation study was to study the correlation between the Spanish translation of the American Academy of Orthopaedic Surgeons Foot and Ankle Outcomes questionnaire (AAOS-FAOQ) and the Spanish versions of the Foot Function Index (FFI) and the Foot Health Status Questionnaire (FHSQ) in Hispanics from Mexican lineage with traumatic foot and ankle injuries.Methods:A cross-sectional validation study in 36 Hispanic patients from Mexican lineage with foot and ankle injuries was performed. The Hispanic version of the AAOS-FAOQ and the Spanish translations of the FAOQ, FHSQ, FFI, and the Short-Form 36 questionnaire (SF-36) were distributed among all patients. Subsequent statistical analysis correlating the Hispanic version of the AAOS-FAOQ to the FFI, FHSQ, and SF-36 was performed. Additional analysis on the Hispanic AAOS-FAOQ included test–retest reliability and internal consistency.Results:The Hispanic AAOS-FAOQ Global Foot and Ankle subscale showed statistically significant (P < .05) correlations with 5 of 8 subscales of the FHSQ, the FFI, and the Physical Component Summary subscale of the SF-36. The AAOS-FAOQ Global Foot & Ankle Scale also demonstrated a test–retest reliability of 0.736 and a strong internal consistency.Conclusions:This study further validates AAOS-FAOQ in Mexican Hispanics by showing strong correlations with the validated Spanish versions of the FFI and FHSQ.

Outcomes following limb salvage after combat hindfoot injury are inferior to delayed amputation at five years.

ObjectivesThe surgical challenge with severe hindfoot injuries is one of technical feasibility, and whether the limb can be salvaged. There is an additional question of whether these injuries should be managed with limb salvage, or whether patients would achieve a greater quality of life with a transtibial amputation. This study aims to measure functional outcomes in military patients sustaining hindfoot fractures, and identify injury features associated with poor function.MethodsFollow-up was attempted in all United Kingdom military casualties sustaining hindfoot fractures. All respondents underwent short-form (SF)-12 scoring; those retaining their limb also completed the American Academy of Orthopaedic Surgeons Foot and Ankle (AAOS F&A) outcomes questionnaire. A multivariate regression analysis identified injury features associated with poor functional recovery.ResultsIn 12 years of conflict, 114 patients sustained 134 fractures. Follow-up consisted of 90 fractures (90/134, 67%), at a median of five years (interquartile range (IQR) 52 to 80 months).The median Short-Form 12 physical component score (PCS) of 62 individuals retaining their limb was 45 (IQR 36 to 53), significantly lower than the median of 51 (IQR 46 to 54) in patients who underwent delayed amputation after attempted reconstruction (p = 0.0351).Regression analysis identified three variables associated with a poor F&A score: negative Bohler’s angle on initial radiograph; coexisting talus and calcaneus fracture; and tibial plafond fracture in addition to a hindfoot fracture. The presence of two out of three variables was associated with a significantly lower PCS compared with amputees (medians 29, IQR 27 to 43 vs 51, IQR 46 to 54; p < 0.0001).ConclusionsAt five years, patients with reconstructed hindfoot fractures have inferior outcomes to those who have delayed amputation. It is possible to identify injuries which will go on to have particularly poor outcomes.Cite this article: P. M. Bennett, T. Stevenson, I. D. Sargeant, A. Mountain, J. G. Penn-Barwell. Outcomes following limb salvage after combat hindfoot injury are inferior to delayed amputation at five years. Bone Joint Res 2018;7:131–138. DOI: 10.1302/2046-3758.72.BJR-2017-0217.R2.

Long-term Follow-up of Revision Osteochondral Allograft Transplantation of the Ankle.

Osteochondral allograft (OCA) transplantation is a useful alternative for treatment of posttraumatic ankle arthritis in young patients but has a relatively high failure rate and further procedures are often required. The purpose of this study was to evaluate outcomes of patients who underwent revision OCA transplantation of the ankle after failed primary OCA transplantation. Twenty patients underwent revision OCA transplantation of the ankle between 1988 and 2015. Mean age was 44 years, 55% (11 of 20) were female. The mean time from primary to revision OCA was 3.0 ± 1.7 years. All patients had a minimum follow-up of 2 years. Outcomes included the American Academy of Orthopaedic Surgeons Foot and Ankle Module (AAOS-FAM) and questionnaires evaluating pain and satisfaction. Failure of the revision OCA was defined as a conversion to arthroplasty, arthrodesis, or amputation. Ten of 20 ankles required further surgery, of which 30% (6 of 20) were considered OCA revision failures (4 arthrodeses, 1 arthroplasty, and 1 amputation). The mean time to failure was 6.7 (range, 0.6-13.1) years. Survivorship of the revision OCA was 84% at 5 years and 65% at 10 years. The 14 patients with grafts remaining in situ had an average follow-up of 10.3 years; mean AAOS-FAM Core Score was 70.5 (range, 42.3-99). Of the patients who answered the follow-up questions, 4 of 7 reported moderate to severe pain, and 5 of 12 were satisfied with the results of the procedure. Although the results of revision ankle OCA transplantation are not inferior to primary OCA transplantation, the high rates of persistent pain, further surgery, and graft failure suggest that the indications for OCA as a revision procedure should be carefully evaluated, with proper patient selection. Considering the treatment alternatives, revising a failed OCA transplantation can be a useful treatment option, especially for young and active patients who wish to avoid arthrodesis or arthroplasty. Level IV, case series.

Outcomes Following Nonoperative Treatment of Isolated Posterior Malleolar Ankle Fractures

Category: Ankle, Trauma Introduction/Purpose: Ankle fractures are common injuries, however isolated posterior malleolar fractures are rare. Axial loading of the foot in hyper-plantarflexion is thought to be the most likely mechanism of injury for this fracture pattern. Management of isolated posterior malleolar fractures presents challenges for clinicians, and controversy exists over surgical indications. The literature to-date examining isolated posterior malleolar fractures is scarce and confined to case reports and small clinical series. Recommendations for surgical treatment are based largely on biomechanical studies and not clinical evidence. The purpose of this study was to assess outcomes in a series of patients, who were consecutively treated nonoperatively for isolated posterior malleolus ankle fractures. Methods: Outcomes of patients with isolated posterior malleolus fractures who were all treated nonoperatively at two academic teaching hospitals were retrospectively reviewed. The size of the posterior malleolar fracture fragment was measured on lateral ankle radiographs, and clinical outcomes were evaluated using the American Academy of Orthopaedic Surgeons (AAOS) Foot and Ankle Survey. These scores were then compared to published normative data from the general population via independent t-tests. These same outcome measures were then correlated with the size of the posterior malleolar fragment via Spearman Rank Correlations. Results: A total of 28 patients (17 male, 11 female) were retrospectively reviewed. The average size of the posterior malleolus fragment was 16.0% (Range: 2.0-59.5%) of the tibial plafond articular surface. The average follow-up duration was 2 years and 7 months. At follow-up, the average “Foot and Ankle Core Score” and “Shoe Comfort Scale Score” were 90 (±11.2) and 80.0 (±28.9), respectively. When these scores were compared to normative data from the general population, no significant differences were found (Foot and Ankle Core Score: p=0.234, Shoe Comfort Scale: p=0.276). There was also no significant association between these scores and the size of fracture fragment. At follow-up, no patients demonstrated signs of instability, dermatological complications, malalignment of the mortise or post-traumatic arthritis. Conclusion: This is the largest study to date evaluating outcomes of isolated posterior malleolus fractures in patients treated nonoperatively. This series of 28 patients with isolated posterior malleolar fractures managed nonoperatively demonstrates short- to mid-term functional outcomes that are no different than reported normative data for the general population. These findings are consistent with previously reported clinical outcomes and suggest that nonoperative management is a viable treatment option for isolated posterior malleolar fractures.

Spanish Translation, Cross-Cultural Adaptation, and Validation of the American Academy of Orthopaedic Surgeons Foot and Ankle Outcomes Questionnaire in Mexican-Americans With Traumatic Foot and Ankle Injuries.

Hispanics represent the largest minority group within the US population accounting for an estimated 55.4 million individuals. Enrolling Hispanics into clinical outcome studies is important in order for study populations to be externally valid and representative of the US population. Inclusion of Mexican-Americans in clinical studies is frequently limited by the lack of validated outcome measures. The goal of this study was to validate a Spanish version of the American Academy of Orthopaedic Surgeons Foot and Ankle Outcomes Questionnaire (AAOS-FAOQ) in Mexican-Americans with traumatic foot and ankle injuries. The translation and cross-cultural adaptation procedure was performed by a committee of bilingual speakers using the following steps: (1) forward translation and adaptation, (2) synthesis, (3) back translation, (4) committee review, and (5) pilot testing. The validation was performed in 100 Mexican-Americans with traumatic foot and ankle injuries. A total of 41 females and 59 males were enrolled in this study. The mean age was 42.98 years (range 18-88). The Spanish version of the Global Foot and Ankle Scale of the AAOS-FAOQ showed statistically significant correlations with all 8 subscales of the Spanish SF-36 as well as the Physical Component Summary scale and the Mental Component Summary scale (P < 0.05). The Global Foot and Ankle scale of the Spanish AAOS-FAOQ demonstrated a test-retest reliability of 0.68. We provide a Spanish translation and cross-cultural adaptation of the AAOS-FAOQ. The instrument demonstrates appropriate psychometric properties in Mexican-Americans with traumatic foot and ankle injuries.

Surgery for Type B Ankle Fracture Treatment: a Combined Randomised and Observational Study (CROSSBAT)

BackgroundIsolated type B ankle fractures with no injury to the medial side are the most common type of ankle fracture.ObjectiveThis study aimed to determine if surgery is superior to non-surgical...

Clinical and Radiographic Outcomes of Foot Orthosis for Hallux Valgus

Category: Bunion Introduction/Purpose: Nonoperative care, which is safer and costs less than operative treatment, is the first-line treatment for hallux valgus. Despite numerous studies have reported results of operative treatments, little information is available on the efficacy of nonoperative treatments for hallux valgus. Foot orthosis, or shoe insole, is one of the most widely used nonoperative treatments. Torkki et al. compared orthotic treatment with operative treatment in a randomized controlled trial, however the subjects were patients who planned to undergo hallux valgus surgery, and thus the patient background was different from clinical setting. It is also controversial whether orthotic treatment can prevent the progression of toe deformity. This prospective one- year follow-up study was conducted to evaluate clinical and radiographic outcomes of foot orthosis for painful hallux valgus. Methods: Patients were recruited prospectively at the foot and ankle clinic of our university hospital from 2011 to 2014. Inclusion criteria were patients over 20 years old, with hallux valgus angle (HVA) greater than 20 degrees, and having a painful hallux and/or forefoot. Patients were informed of both surgical and orthotic treatments regardless of the severity of deformity, and those who selected orthotic treatment were included. One certified orthotist made custom-made total contact insoles, and patients were instructed to wear them as long as possible. Clinical evaluations were performed at baseline, 6 and 12 months. The evaluations included visual analog scale (VAS) for pain, American Academy of Orthopaedic Surgeons (AAOS) foot and ankle score, and SF-36. Patients also reported mean hours a day to wear the orthosis, and treatment satisfaction using VAS at 6 and 12 months. HVA and intermetatarsal angle were measured with the radiographs at baseline and 12 months. Results: Of 158 patients visiting the clinic, 65 patients selected orthotic treatment, and thus included in this study. Mean pain VAS was 48.1 at baseline, and it decreased significantly at 6 months (27.7, p &lt; 0.001). However, it increased slightly at 12 months, although it was still lower than the baseline value (30.6, p=0.002). The AAOS Core Scale was 36.1 at baseline, and it improved significantly at 6 months (42.3, p &lt; 0.001). However the effect of orthosis diminished at 12 month (39.8, p=0.2). The same trend was found for the bodily pain of the SF-36. Patient satisfactions were 54.1 and 54.7 at 6 and 12 months, respectively. The mean HVA and intermetatarsal angle were 41.1 degrees and 17.4 degrees at baseline, and they did not change at 12 months. Conclusion: Wearing total contact shoe insole improved pain and functional outcomes for patients with painful hallux valgus, and the treatment effect lasted for at least 12 months. However, the effect was maximal at 6 months, and diminished slightly at 12 months. Therefore a longer follow-up study is necessary to assess how long the effect will continue. Additionally, the orthotic treatment in this study had no effect on hallux valgus deformity over a 12 month period.