Talar neck rotation angle in adults with clubfoot deformity: Observed values and intra- and inter-observer reliability using weightbearing CT.

INTRODUCTION: Adults presenting with symptomatic clubfoot represent a challenging cohort of patients. An appreciation of the location and degree of deformities is essential for management. Talar anatomy is often abnormal with varus within the talar neck, however, there are few reproducible methods which quantify talar neck deformity in adults. We describe a technique of assessing talar neck deformity, and report on observed values and intra- / inter-observer reliability. METHODS: This was a single-centre, retrospective study including 96 feet from 56 adult patients with clubfeet (82 feet had clubfoot deformity, 14 were normal). Mean age was 34.3 ± 16.9 years and 31 (55.3%) were male. Weight-bearing CT scans captured as part of routine clinical care were analysed. Image reformats were oriented parallel to the long axis of the talus in the sagittal plane. In the corresponding axial plane two lines were drawn (on separate slices): 1) a line perpendicular to the intermalleolar axis, 2) a line connecting the midpoints of the talar head and narrowest part of the talar neck. The talar neck rotation angle (TNR angle) was the angle formed between these lines. Intraclass correlation coefficients (ICC) were performed for intra- and inter-observer reliability. RESULTS: Mean TNR angle in clubfeet was 27.6 ± 12.2 degrees (95%CI = 25.0 to 30.2 degrees). Mean TNR angle in normal feet was 18.7 ± 5.1 degrees (95%CI = 16.0 to 21.4 degrees) (p < 0.001). The ICC for clubfeet was 0.944 (95%CI = 0.913 to 0.964) for intra-observer agreement, and 0.896 (95%CI = 0.837 to 0.932) for inter-observer agreement. CONCLUSION: This measurement technique demonstrated excellent intra- and inter-observer agreement. It also demonstrated that compared to normal feet, clubfeet had about 9 degrees of increased varus angulation of the talar neck. This technique and data may be used for future research into clubfoot deformity and in planning treatment. LEVEL OF CLINICAL EVIDENCE: 3.

Assessing the coronal plane deformity in Charcot Marie Tooth Cavovarus feet using automated 3D measurements.

BACKGROUND: This study assesses the coronal-plane deformities in cavovarus feet secondary to Charcot-Marie-Tooth disease (CMT) using Weightbearing-CT (WBCT) and semi-automated 3D-segmentation software. METHODS: WBCTs from 30 CMT-cavovarus feet were matched to 30 controls and analysed using semi-automatic 3D-segmentation (Bonelogic, DISIOR). The software used automated cross-section sampling with subsequent straight-line representation of weighted centre points to calculate 3D axes of bones in the hindfoot, midfoot and forefoot. Coronal relationships of these axes were analysed. Supination/pronation of the bones in relation to the ground and within each joint were measured and reported. RESULTS: The most significant deformity in CMT-cavovarus feet occurred at the talonavicular joint (TNJ) with 23 degrees more supination than normal feet (6.4 ± 14.5 versus 29.4 ± 7.0 degrees, p < 0.001). This was countered by relative pronation at the naviculo-cuneiform joints (NCJ) of 7.0 degrees (-36.0 ± 6.6 versus -43.0 ± 5.3 degrees, p < 0.001). Combined hindfoot varus and TNJ supination resulted in an additive supination effect not compensated by NCJ pronation. The cuneiforms in CMT-cavovarus feet were therefore supinated by 19.8 degrees to the ground relative to normal feet (36.0 ± 12.1 versus 16.2 ± 6.8 degrees, p < 0.001). The forefoot-arch and 1st metatarsal-ground angles demonstrated similar supination to the cuneiforms suggesting no further significant rotation occurred distally. CONCLUSION: Our results demonstrate coronal plane deformity occurs at multiple levels in CMT-cavovarus feet. Majority of the supination arises at the TNJ, and this is partially countered by pronation distally, mainly at the NCJ. An understanding of the location of coronal deformities may help when planning surgical correction. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Semi-automated 3-dimensional analysis of the normal foot and ankle using weight bearing CT - A report of normal values and bony relationships.

BACKGROUND: Foot and ankle deformities have translational and rotational components in multiple planes, at multiple levels. Semi-automatic segmentation is a relatively new technology, which when used with weight-bearing CT (WBCT), can build an accurate model of the foot and calculate the orientation and relationships of bones under physiological load. However, few papers report reference values using these techniques. We report normative values for key bony relationships based on semi-automated analysis of WBCT. METHODS: This was a single-centre, retrospective analysis of 100 feet without deformity from 55 adult patients undergoing WBCT as part of routine clinical activity (mean age 40.5 ± 17.3 years). Imaging was analysed using Bonelogic 2.1 (DISIOR, Finland). Semi-automatic segmentation was used to compute the various bony axes in 3-dimensional space. Selected coronal, axial and sagittal plane relationships were then calculated for bones of the hindfoot, midfoot and forefoot. RESULTS: Data is presented on axial and sagittal plane relationships between the metatarsals in the forefoot, and the metatarsals and cuneiforms in the midfoot. In the hindfoot, the calcaneal pitch, talar-first-metatarsal angles, talonavicular coverage angles and Saltzman angles are reported. Coronal plane axes and their relationships are reported at multiple levels from hindfoot to forefoot. Results are presented as mean values with standard deviations and 95% confidence intervals. CONCLUSIONS: We present an observational analysis of the normal values from non-deformed feet. We highlight the major relationships in the axial, sagittal and coronal planes as obtained by semi-automated analysis of WBCT. This data may serve as a reference for future research. LEVEL OF EVIDENCE: Basic science study.

Use of intramedullary locking nail for displaced intraarticular fractures of the calcaneus: what is the evidence?

INTRODUCTION: Intramedullary locking devices (ILDs) have recently been advocated as a minimally invasive approach to manage displaced intraarticular calcaneal fractures (DIACFs), to minimise complications and improve outcomes. We reviewed clinical and biomechanical studies dealing with commercially available devices to identify their characteristics, efficacy and safety. METHODS: Following a PRISMA checklist, Medline, Scopus and EMBASE databases were searched to identify studies reporting the use of ILDs for treating DIACFs. Biomechanical studies were first evaluated. Cohort studies were then reviewed for demographics, surgical technique, postoperative protocol, clinical and radiographic scores, complications and reoperations. The modified Coleman Methodology Score (CMS) was used to assess the quality of studies. RESULTS: Eleven studies were identified which investigated two devices (Calcanail®, C-Nail®). Three biomechanical studies proved they offered adequate primary stability, stiffness, interfragmentary motion and load to failure. Eight clinical studies (321 feet, 308 patients) demonstrated a positive clinical and radiographic outcome at 16-months average follow-up. Metalware irritation (up to 20%) and temporary nerve entrapment symptoms (up to 30%) were the most common complications, while soft tissue issues (wound necrosis, delayed healing, infection) were reported in 3-5% of cases. Conversion to subtalar fusion was necessary in up to 6% of cases. Four (50%) out of 8 studies were authored by implant designers and in 5 (62%) relevant conflicts of interest were disclosed. Mean (± standard deviation) CMS was 59 ± 9.8, indicating moderate quality. CONCLUSIONS: Treating DIAFCs with ILDs leads to satisfactory clinical outcomes at short-term follow-up, enabling restoration of calcaneal height and improved subtalar joint congruency. Metalware irritation and temporary nerve entrapment symptoms are common complications although wound complications are less frequent than after open lateral approaches. The quality of evidence provided so far is moderate and potentially biased by the conflict of interest, raising concerns about the generalisability of results. LEVEL OF EVIDENCE: Level V - Review of Level III to V studies.

The use of intramedullary devices for fixation of metatarsal osteotomies in hallux valgus surgery - A systematic review.

BACKGROUND: Hallux valgus is a common foot condition with numerous surgical techniques described. Minimally invasive surgery is becoming more popular, with resultant development of suitable fixation devices. The aim of this systematic review was to evaluate the evidence on the use of intramedullary devices in hallux valgus first metatarsal corrective osteotomies, and describe clinical and radiological outcomes, with an overview of techniques and implants used. METHODS: We searched PubMed, Medline, Embase and EMCare databases, conforming to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Radiological outcomes including the hallux valgus angle (HVA) and intermetatarsal angle (IMA) were recorded, as well as clinical outcome scores and complications. Methodological quality of included studies was assessed using the MINORS score. RESULTS: Ten studies were included, comprising 696 feet in 745 patients. Data pooling and metanalysis was not possible due to overall low quality of evidence. Four implants were reported (Endolog, ISO Plate, V-Tek Plate, Link Fixator) and used with distal first metatarsal osteotomies, with improvement in HVA, IMA, and clinical outcome scores comparable to other fixation techniques. There were no reported cases of non-union. Complication rates were variable (all cause range of 0-21%) across all studies, with an overall low rate. CONCLUSION: Intramedullary devices are viable and safe to use for hallux valgus first metatarsal osteotomies, with comparable radiological and functional outcomes to other techniques. Current evidence base is of low methodological quality, therefore high quality studies are required to further evaluate these devices.

Limb salvage versus below knee amputation for severe adult lower limb deformity - A retrospective, comparative series.

BACKGROUND: This study compares outcomes of patients with severe, multiplanar, fixed, pantalar deformities undergoing limb preservation with either pantalar fusion (PTF) or talectomy and tibiocalcaneal fusion (TCF), versus below knee amputation (BKA). METHODS: Fifty-one patients undergoing either PTF, TCF and BKA for failed management of severe pantalar deformity were evaluated retrospectively. Twenty-seven patients underwent PTF, 8 TCF and 16 BKA. Median age at surgery was 55.0 years (17-72 years) and median follow-up duration was 49.9 months (24.0-253.7 months). Clinical evaluation was undertaken using the MOxFQ, EQ-5D and Special Interest Group in Amputee Medicine score (SIGAM). Patients were also asked whether they were satisfied with their surgery and whether they would have the same surgery again. RESULTS: There was no statistically significant difference in functional outcomes, satisfaction, or complications between the groups. Twenty-two patients undergoing PTF (81.5%), 6 patients undergoing TCF (75%), and 15 patients undergoing BKA (93.8%) were satisfied overall (p = 0.414). There was no difference in the proportion of patients who would opt for the same procedure again (p = 0.142): 23 in the PTF group (85.2%), 8 in the TCF group (100%), and 11 in the BKA group (68.8%). Seven patients undergoing PTF (25.9%), 2 patients undergoing TCF (25%) and 6 patients undergoing BKA (37.5%) had major complications (p = 0.692). CONCLUSION: This study concludes that PTF, TCF and BKA can all provide an acceptable outcome in treatment of severe, degenerative pantalar deformities. This data may be useful in counselling patients when considering salvage versus amputation in such cases. LEVEL OF EVIDENCE: Level 3(Original) Clinical Research Article.

Static versus dynamic fixation of distal tibiofibular syndesmosis: a systematic review of overlapping meta-analyses.

PURPOSE: Multiple Level I meta-analyses were conducted comparing traditional static vs. more recently introduced dynamic strategies of fixation for injuries of the distal tibiofibular syndesmosis (TFS). The aim of this review was to assess their robustness and methodological quality, providing support in the choice of a treatment strategy in case of TFS injury using the highest level of evidence. METHODS: In this systematic review, conducted in accordance with the PRISMA guidelines, meta-analyses/systematic reviews comparing static and dynamic fixation methods after acute TFS injury were identified. The robustness of studies was evaluated using the fragility index (FI) for meta-analysis and the fragility quotient (FQ). The risk of bias was evaluated using the Assessment of Multiple Systematic Reviews (AMSTAR) instrument. Finally, the Jadad was applied to select the study which provided the highest quality of evidence to develop recommendations for the fixation strategy of these lesions. RESULTS: Out of 1.302 records, four Level I meta-analyses were included in this study. Analyzing the statistically significant dichotomous outcomes, the median FI was 3.5 (IQR, 2 to 5.5; range, 1 to 9), while the median FQ was 1.9% (IQR, 1 to 3.5; range 0.35 to 4.4). In total, 37% had an FI of 2 or less and 75% of outcomes had a FI of 4 or less. According to the AMSTAR score and Jadad algorithm, the largest meta-analysis was selected as the highest evidence provided so far. CONCLUSION: The meta-analyses with statistically significant dichotomous outcomes comparing dynamic and static fixation for treating injuries of the distal tibiofibular syndesmosis are fragile, with a change in less than four patients or less than 2% of the study population sufficient to reverse a significant outcome to nonsignificant. LEVEL OF EVIDENCE: Level I.

Pes cavovarus in Charcot-Marie-Tooth compared to the idiopathic cavovarus foot: A preliminary weightbearing CT analysis.

BACKGROUND: Pes cavovarus is a foot deformity that can be idiopathic (I-PC) or acquired secondary to other pathology. Charcot-Marie-Tooth disease (CMT) is the most common adult cause for acquired pes cavovarus deformity (CMT-PC). The foot morphology of these distinct patient groups has not been previously investigated. The aim of this study was to assess if morphological differences exist between CMT-PC, I-PC and normal feet (controls) using weightbearing computed tomography (WBCT). METHODS: A retrospective analysis of WBCT scans performed between May 2013 and June 2017 was undertaken. WBCT scans from 17 CMT-PC, 17 I-PC and 17 healthy normally-aligned control feet (age-, side-, sex- and body mass index-matched) identified from a prospectively collected database, were analysed. Eight 2-dimensional (2D) and three 3-dimensional (3D) measurements were undertaken for each foot and mean values in the three groups were compared using one-way ANOVA with the Bonferroni correction. RESULTS: Significant differences were observed between CMT-PC or I-PC and controls (p<0.05). Two-dimensional measurements were similar in CMT-PC and I-PC, except for forefoot arch angle (p=0.04). 3D measurements (foot and ankle offset, calcaneal offset and hindfoot alignment angle) demonstrated that CMT-PC exhibited more severe hindfoot varus malalignment than I-PC (p=0.03, 0.04 and 0.02 respectively). CONCLUSIONS: CMT-related cavovarus and idiopathic cavovarus feet are morphologically different from healthy feet, and CMT feet exhibit increased forefoot supination and hindfoot malalignment compared to idiopathic forms. The use of novel three-dimensional analysis may help highlight subtle structural differences in patients with similar foot morphology but aetiologically different pathology. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Intraobserver and interobserver reliability of cone beam weightbearing semi-automatic three-dimensional measurements in symptomatic pes cavovarus.

INTRODUCTION: Pes cavovarus is a three-dimensional (3D) foot deformity. New 3D semi-automatic measurements utilising weightbearing computerised topography (WBCT) images have recently been proposed to assess hindfoot alignment, but reliability in pes cavovarus has never been investigated. The aim of this study was to assess intraobserver and interobserver reliability of the foot ankle offset (FAO), calcaneal offset (CO) and hindfoot alignment angle (HAA) in pes cavovarus. METHODS: Anonymised WBCT datasets from 51 feet (17 Charcot-Marie-Tooth related cavovarus, 17 idiopathic cavovarus and 17 controls) were retrospectively reviewed. Three observers (two senior foot and ankle fellows and one orthopaedic resident) independently measured FAO, CO and HAA using dedicated software, with measurements repeated two weeks apart. Subgroup analysis was performed to assess whether aetiology or severity of varus deformity and level of seniority affected reliability. RESULTS: Mean values for intra and interobserver reliability for FAO (r=0.98; ICC: 0.99), CO (r=0.97; ICC: 0.98) and HAA measurements (r=0.97; ICC: 0.98) were excellent. Subgroup analyses showed that FAO, CO and HAA's intra (r/ρ range, 0.77-0.95) and interobserver (ICC range, 0.88-0.98) reliability remained excellent in patients with Charcot-Marie-Tooth related cavovarus, idiopathic pes cavovarus and normal feet, regardless of the severity of deformity. No difference was found in FAO, CO and HAA mean values from three observers (p>0.05 in all cases). DISCUSSION: This study demonstrates that 3D semi-automatic measurements of WBCT images have excellent intra and interobserver reliability in the assessment of hindfoot alignment in pes cavovarus. Aetiology and severity of deformity, and level of seniority do not affect reliability of these measurements. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

First Metatarsophalangeal Joint Arthrodesis Using an Intraosseous Post and Lag Screw With Immediate Bearing of Weight.

Arthrodesis is the gold standard procedure for advanced arthrosis of the first metatarsophalangeal joint. Having a strong construct is preferable for allowing immediate bearing of weight, which facilitates patient rehabilitation. Plate and screw fixation is currently in favor but can lead to prominent metalware necessitating removal. The aim of this study is to report the results of a series of 54 first metatarsophalangeal joint arthrodeses performed in 52 patients treated with an implant composed of an intraosseous post and lag screw. All of the patients had a minimum follow-up of 1 year, and the indication for the surgery was end-stage hallux rigidus in 44 (81.5%) feet, severe hallux valgus in 8 (14.8%) feet, and rheumatoid arthritis in 2 (3.7%) feet. Arthrodesis was achieved in 52 (96.3%) feet at a mean of 61 ± 16 (range 39 to 201) days with nonunion observed in 2 (3.7%) feet; neither of the 2 patients had known risk factors. Metalware impinging on soft tissues necessitating removal was observed in 3 (5.6%) feet, and there were no cases of loss of position or implant breakage. The mean Manchester-Oxford Foot Questionnaire score improved from 46.4 ± 13.3 to 18.4 ± 9.4 (p < .001) at latest follow-up. In conclusion, our results suggest the intraosseous post and lag screw device was safe and effective, and it can be considered an alternative method of stabilizing the first metatarsophalangeal joint when undertaking arthrodesis surgery.

Forefoot Morphotypes in Cavovarus Feet: A Novel Assessment of Deformity.

BACKGROUND: The cavovarus foot is a complex 3-dimensional deformity. Although a multitude of techniques are described for its surgical management, few of these are evidence based or guided by classification systems. Surgical management involves realignment of the hindfoot and soft tissue balancing, followed by forefoot balancing. Our aim was to analyze the pattern of residual forefoot deformities once the hindfoot is corrected, to guide forefoot correction. METHODS: We included 20 cavovarus feet from 16 adult patients with Charcot-Marie-Tooth who underwent weightbearing CT (mean age 43.4 years, range: 22-78 years, 14 males). Patients included had flexible deformities, with no previous surgery. Using specialized software (Bonelogic 2.1, Disior) a 3-dimensional, virtual model was created. Using morphologic data captured from normal feet in patients without pathology as a guide, the talonavicular joint of the cavovarus foot was digitally reduced to a "normal" position to simulate the correction that would be achieved during surgical correction. Models of the corrected position were exported and geometrically analyzed using Blender 3.64 to identify anatomical trends. RESULTS: We identified 4 types of cavovarus forefoot morphotypes. Type 0 was defined as a balanced forefoot (2 cases, 10%). Type 1 was defined as a forefoot where the first metatarsal was relatively plantarflexed to the rest of the foot, with no significant residual adduction after talonavicular joint correction (12 cases, 60%). Type 2 was defined as a forefoot where the second and first metatarsals were progressively plantarflexed, with no significant adduction (4 cases, 20%). Type 3 was defined as a forefoot where the metatarsals were adducted after talonavicular derotation (2 cases, 10%). CONCLUSION: In this relatively small cohort, we identified 4 forefoot morphotypes in cavovarus feet that might help surgeons to recognize and anticipate the residual forefoot deformities after hindfoot correction. Different treatment strategies may be required for different morphotypes to achieve balanced correction. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Classifications in adult pes cavus - A scoping review.

AIMS: The adult cavus foot represents a challenging clinical problem, with varied aetiology and complex, 3-dimensional deformities. Thus far, the cavus foot has eluded a unified classification. The aim of this paper was to appraise the literature to identify classification systems which guide the operative management of neurological cavus feet in adults. METHODS: As the aim of this paper was broad, a scoping review was conducted. The review was conducted in line with published frameworks. Our principal research question was 'what classification systems that guide surgical management currently exist for neurological cavus feet in adults'. We searched CINAHL, Embase, OVID, Proquest, Pubmed, Scopus and Web of Science databases using MESH and non-MESH terms. Two authors independently reviewed abstracts / papers and a data extraction sheet was used to collect the relevant data. RESULTS: A total of 1140 articles were initially screened, identifying 125 articles for which a full text review was performed. Only three articles met all our inclusion criteria. All these articles reported an anatomical classification with suggestions for treatment based on the classification. All were considered to comprise Level V evidence, and none reported outcomes of treatment based on the classification. CONCLUSIONS: There is currently a paucity of robust classifications to guide treatment in neurological cavus feet in adults. The few classifications systems that exist are varied and do not as yet have sufficient evidence to support their widespread use. Further work is required, aimed at identifying specific features of cavus feet that would guide operative treatment.

Initial implant stability predicts migration but not failure in cementless acetabular revision with bone grafting.

Host bone contact of less than 50% is perceived but not proven to cause migration and loosening after acetabular revision. A prospective analysis of cementless acetabular revision cases with impaction grafting was performed to determine if this was an independent risk factor for these events. Sixty-two hips in 54 patients were assessed at a mean follow-up of 84.5 months (range 61-112) yielding a probability of 94.6% of retaining the acetabular component using revision for aseptic loosening as the end point. No single factor was independently causative for loosening, although Type III fixation was associated with migration (p=0.0159); subanalysis suggested that achieving host-bone contact in at least part of the dome and posterior column is important.

What is the best fixation technique for isolated talonavicular arthrodesis? - A systematic review.

Talonavicular arthrodesis is associated with a rate of non-union that ranges from 3 % to 37 %. Various fixation devices have been reported for talonavicular arthrodesis including screws, staples, plates, K-wires and intraosseous fix systems, however there is no definitive gold standard. This systematic review aims to compare clinical outcomes between different fixation devices for talonavicular arthrodesis. METHODS: MEDLINE, EMBASE, CENTRAL and Google Scholar were reviewed for studies reporting on outcomes of different fixation techniques for talonavicular arthrodesis indicated for osteoarthritis, inflammatory and post-traumatic arthritis from 1946 to 2021. The primary outcome measure was union rate. Secondary outcome measures included functional improvement, cost, quality of life and patient satisfaction. RESULTS: 9 articles involving 141 cases of talonavicular arthrodesis were identified. Fusion rates were as follows: screw fixation (n = 75): 87.5 % to 100 %, staple fixation (n = 13): 100 %, intraosseous fix system (n = 16): 100 %, and K-wire fixation (n = 2): 100 %. One study utilised a dorsal locking plate with two supplemented compression screws (n = 9, fusion rate= 100 %) and two studies used a combination of screws with staples (n = 26, fusion rate= 96 %). 7 of 9 studies measured functional outcomes and pain relief with improvement demonstrated in all fixation techniques. Quality of life, satisfaction and cost were inadequately reported amongst the included studies. All studies were rated as serious risk of bias. CONCLUSION: This systematic review consolidates the evidence for outcomes of different fixation techniques for TN arthrodesis, however a definitive judgement regarding the best fixation technique is unobtainable from current clinical evidence, due to lack of high-quality studies. With review of biomechanical studies and the limited clinical data, fixation with plate plus screw is most promising and would warrant further comparative study. LEVEL OF EVIDENCE: IV.

Analysis of the 50 Most Cited Articles on Achilles Tendon Injury.

Background: Achilles tendon injuries represent one of the most common reasons for referral to orthopaedic surgeons. Purpose: To outline the characteristics, examine trends in publication, and evaluate the correlation between citations and study quality of the 50 most cited articles on Achilles tendon injury. Study Design: Cross-sectional study. Methods: After searching the Web of Science for articles published in orthopaedic journals, we identified the 50 most cited articles on Achilles tendon injury and abstracted their characteristics. Risk of bias was assessed using the modified Coleman Methodology Score (mCMS). Multiple bivariate analyses (Pearson or Spearman correlation coefficient) were used to evaluate the association among number of citations, citation rate (citations/year), 2020 journal impact factor (JIF), year of publication, level of evidence (LoE), study type (tendon rupture or chronic tendinopathy), sample size, and mCMS. Results: The top 50 articles were cited 12,194 times. Each article had a mean ± SD 244 ± 88.8 citations (range, 157-657) and a citation rate of 12.6 ± 5.4 per year (range, 3-28). A total of 35 studies (70%) were published between 2000 and 2010. The citation rate of the 16 most recent studies was almost double that of the 16 oldest studies (17.5 vs 9.9; P < .001). Nineteen studies (49%) were classified as having poor quality (mCMS <50 points). The mean JIF of the 9 journals that published the studies was 5.1. The citation rate correlated with the number of citations (r = 0.56; P < .001), publication year (r = 0.60; P < .001), and LoE (r = -0.44; P = .005). The publication year correlated with the LoE (r = -0.40; P = .01). Study quality in terms of mCMS correlated with the JIF (r = 0.35; P = .03) and LoE (r = -0.48; P = .003) but not the citation rate (P = .15). Conclusion: The mean LoE and the citation rate of the most cited articles on Achilles tendon injury both significantly increased over time. Although the JIF was positively correlated with study quality, almost half of the studies had poor-quality methodology.

Outcomes of Tenosynovial Giant Cell Tumor of the Foot and Ankle.

BACKGROUND: Tenosynovial giant cell tumor (TGCT) is a benign proliferative disease affecting synovial membranes. There are 2 forms, localized (L-TGCT) and diffuse (D-TGCT), which although histologically similar behave differently. It is locally invasive and is treated in most cases by operative excision. The aim of this study was to assess current practice, how the patients' presentation affected their outcome, as well as review the recurrence rates and complications. METHODS: A retrospective analysis of 123 cases was performed in patients treated between 2003 and 2019 with TGCT of the foot and/or ankle. Data were collected on age at presentation, radiologic pattern of disease, location of disease, treatment provided, and recurrence rates. The minimum follow-up was 2 years with a mean of 7.7 years. RESULTS: There were 61.7% female patients with a mean age of 39 (range, 11-76) years. L-TGCT accounted for 85 (69.1%) cases and D-TGCT for 38 (30.9%). The most prevalent preoperative symptoms were a palpable mass (78/123) and pain (65/123). Radiologically confirmed recurrence in the operative group was noted in 14.5% (16/110) cases. This comprised 4% (3/75) of operatively treated L-TGCT and 37% (13/35) of operatively treated D-TGCT. Patients with pain on presentation and those with erosive changes on presenting magnetic resonance imaging (MRI) were more likely to have persistent postoperative pain (P < .001 for both). Where patients had both preoperative pain and erosive changes, 57.1% had postoperative pain. Thirteen cases were managed nonoperatively where symptoms were minimal, with 1 case requiring surgery at a later date. CONCLUSION: Outcomes of TGCT management are dependent on the disease type, extent of preoperative erosive changes, and presence of preoperative pain. These data are useful for counseling patients regarding the outcomes of surgical intervention and help guide the timing of intervention. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

First Metatarsal Rotation After Scarf Osteotomy for Hallux Valgus.

BACKGROUND: Recurrence after surgical correction of hallux valgus may be related to coronal rotation of the first metatarsal. The scarf osteotomy is a commonly used procedure for correcting hallux valgus but has limited ability to correct rotation. Using weight-bearing computed tomography (WBCT), we aimed to measure the coronal rotation of the first metatarsal before and after a scarf osteotomy, and correlate these to clinical outcome scores. METHODS: We retrospectively analyzed 16 feet (15 patients) who had a WBCT before and after scarf osteotomy for hallux valgus correction. On both scans, hallux valgus angle (HVA), intermetatarsal angle (IMA), and anteroposterior/lateral talus-first metatarsal angle were measured using digitally reconstructed radiographs. Metatarsal pronation angle (MPA), alpha angle, sesamoid rotation angle, and sesamoid position were measured on standardized coronal WBCT slices. Preoperative and postoperative (12 mo) clinical outcome scores (Manchester Oxford Foot Questionnaire and Visual Analogue Scores) were captured. RESULTS: Mean HVA was 28.6 ± 10.1° preoperatively and 12.1 ± 7.7° postoperatively (P < .001). Mean IMA was 13.7 ± 3.8° preoperatively and 7.5 ± 3.0° postoperatively (P < .001). Before and after surgery, there were no significant differences in MPA (11.4 ± 7.7 and 11.4 ± 9.9°, respectively; P = .75) or alpha angle (10.9 ± 8.0 and 10.7 ± 13.1°, respectively; P = .83). There were significant improvements in sesamoid rotation angle (SRA) (26.4 ± 10.2 and 15.7 ± 10.2°, respectively; P = .03) and sesamoid position (1.4 ± 1.0 and 0.6 ± 0.6, respectively; P = .04) after a scarf osteotomy. There were significant improvements in all outcome scores after surgery. Poorer outcome scores correlated with greater postoperative MPA and alpha angles (r = .76 (P = .02) and .67 (P = .03), respectively). CONCLUSION: A scarf osteotomy does not correct first metatarsal coronal rotation, and worse outcomes are linked to greater postoperative metatarsal rotation. Rotation of the metatarsal needs to be measured and considered when planning hallux valgus surgery. Further work was needed to compare postoperative outcomes with rotational osteotomies and modified Lapidus procedures when addressing rotation.Level of Evidence: 4.

Aggressive early débridement for treatment of acutely infected cemented total hip arthroplasty.

BACKGROUND: Up to 2% of THAs are complicated by infection, leading to dissatisfied patients with poor function and major social and economic consequences. The challenges are control of infection, restoration of full function, and prevention of recurrence. Irrigation and débridement with or without exchange of modular components remains an attractive alternative to two-stage reimplantation in acutely infected THAs but with variable results from previous studies. QUESTIONS/PURPOSES: We therefore determined the rate at which aggressive early débridement with exchange of modular components controlled acutely infected cemented THAs. METHODS: We retrospectively studied all 26 patients presenting with acutely infected cemented THAs (16 primaries, 10 revisions) occurring within 6 weeks of the index operation or of hematogenous spread from a confirmed source of infection elsewhere between 1999 and 2006. Microbiology confirmed bacterial colonization in all patients, with 18 early postoperative infections and eight acute hematogenous infections. Patients underwent aggressive débridement with open complete synovectomy, exchange of all mobile parts, débridement of all aspects of the joint, irrigation with antiseptic solutions, and pulsatile lavage. Minimum followup was 5 years (mean, 6.6 years; range, 5-11 years). RESULTS: Eight patients had multiple washouts with control of infection in four at latest followup. Five patients underwent two-stage revisions and one patient was placed on long-term antibiotic suppression. Twenty patients returned to their expected functional level with no radiographic evidence of prosthetic failure. At minimum 5-year followup, we had a 77% infection control rate. CONCLUSIONS: Our data confirm current literature and suggest there may be a role for aggressive early débridement in controlling acute postoperative and hematogenous infections after cemented THA. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Trochanteric fixation using a third-generation cable device--minimum follow-up of 3 years.

Third-generation trochanteric fixation cable systems are designed to overcome implant breakage, nonunion, and bony escape. The study prospectively assessed the functional and radiologic outcomes using such an implant. Forty-seven trochanteric fixations in 46 patients were performed over 4 years at 2 institutions using the Accord Cable Plate system (Smith and Nephew, Memphis, Tenn). Serial evaluation at a mean follow-up of 57 months demonstrated that the mean Harris hip scores improved from 52.3 preoperatively to 88.2 postoperatively (P < .001), and the mean pain score improved from 6.2 to 2.3, respectively (P < .001). No cable breakage, fretting, or fraying occurred. There were 2 cases of nonunion. A third-generation cable system appears to improve upon early-generation implants and provide favorable outcomes for reattachment of a trochanteric fragment in a variety of clinical scenarios.

Assessing the Rotation of the First Metatarsal on Computed Tomography Scans: A Systematic Literature Review.

BACKGROUND: Hallux valgus is a multiplanar deformity that is often treated on the basis of 2-dimensional (2D) parameters and radiographs. Recurrence rates after surgical correction remain high, and failure to correct pronation of the metatarsal is increasingly stipulated as being part of the problem. Multiple methods of assessing metatarsal pronation have been proposed. METHODS: We performed a systematic literature review identifying studies that measured metatarsal pronation and torsion on computed tomography (CT) scans. Specific methodology, patient groups, results, and reliability assessments were all reported. RESULTS: We identified 14 studies that fulfilled the inclusion criteria. Eleven studies measured 2D values on CT scan, and 3 studies used computer-based 3-dimensional (3D) modeling and artificial intelligence systems to help calculate pronation. Metatarsal pronation angle, α angle, sesamoid rotation angle, and measurements for torsion were the most commonly used methods. All angles and measurements were performed as 2D measurements, but the metatarsal pronation angle was also performed with 3D modeling. Reliability and reproducibility of the α angle and metatarsal pronation angle were excellent, despite being performed on studies with small numbers. CONCLUSION: Multiple methods have been reported to demonstrate first metatarsal pronation on CT, of which the α angle and the metatarsal pronation angle are the most pragmatic and useful in a clinical setting. Further work is needed to further validate the reliability of these measurements in larger series and to identify normal pronation and metatarsal torsion on weightbearing imaging. Further work is required to determine whether addressing pronation reduces recurrence rates and improves outcomes in surgery for hallux valgus. LEVEL OF EVIDENCE: Level III, retrospective cohort study.