Total Ankle Replacement Versus Arthrodesis for End-Stage Ankle Osteoarthritis: A Randomized Controlled Trial.

BACKGROUND: End-stage ankle osteoarthritis causes severe pain and disability. There are no randomized trials comparing the 2 main surgical treatments: total ankle replacement (TAR) and ankle fusion (AF). OBJECTIVE: To determine which treatment is superior in terms of clinical scores and adverse events. DESIGN: A multicenter, parallel-group, open-label randomized trial. (ISRCTN registry number: 60672307). SETTING: 17 National Health Service trusts across the United Kingdom. PATIENTS: Patients with end-stage ankle osteoarthritis, aged 50 to 85 years, and suitable for either procedure. INTERVENTION: Patients were randomly assigned to TAR or AF surgical treatment. MEASUREMENTS: The primary outcome was change in Manchester-Oxford Foot Questionnaire walking/standing (MOXFQ-W/S) domain scores between baseline and 52 weeks after surgery. No blinding was possible. RESULTS: Between 6 March 2015 and 10 January 2019, a total of 303 patients were randomly assigned; mean age was 68 years, and 71% were men. Twenty-one patients withdrew before surgery, and 281 clinical scores were analyzed. At 52 weeks, the mean MOXFQ-W/S scores improved for both groups. The adjusted difference in the change in MOXFQ-W/S scores from baseline was -5.6 (95% CI, -12.5 to 1.4), showing that TAR improved more than AF, but the difference was not considered clinically or statistically significant. The number of adverse events was similar between groups (109 vs. 104), but there were more wound healing issues in the TAR group and more thromboembolic events and nonunion in the AF group. The symptomatic nonunion rate for AF was 7%. A post hoc analysis suggested superiority of fixed-bearing TAR over AF (-11.1 [CI, -19.3 to -2.9]). LIMITATION: Only 52-week data; pragmatic design creates heterogeneity of implants and surgical techniques. CONCLUSION: Both TAR and AF improve MOXFQ-W/S and had similar clinical scores and number of harms. Total ankle replacement had greater wound healing complications and nerve injuries, whereas AF had greater thromboembolism and nonunion, with a symptomatic nonunion rate of 7%. PRIMARY FUNDING SOURCE: National Institute for Health and Care Research Heath Technology Assessment Programme.

The current standard of Foot and Ankle Fellowship in the UK.

BACKGROUND: The aim of this study was to evaluate the current standards of Fellowship training in Foot and Ankle Surgery Fellowship in the UK. METHODS: Thirteen UK post-FRCS (Tr&Orth) or equivalent Fellows completed a questionnaire detailing their outpatient, surgical, teaching and research experience, along with documenting their supervision and terms of employment. RESULTS: A Fellow attended a mean of 2.5 (0.5-4) clinics and 3.84 (2-7) theatre sessions per week. 62% of Fellows had independent clinics. The three largest sub-specialty areas experienced were forefoot surgery, mid or/hindfoot arthritis and deformity correction. 82% of Fellows had a regular MDT meeting. All were involved in both teaching and research, but only 64% had timetabled research sessions. All Fellows were satisfied with their experience and would recommended the Fellowship. CONCLUSIONS: The current standard of a post FRCS (Tr&Orth) Fellowship in Foot & Ankle surgery in the UK has been defined. Further improvement will require all Fellows to be involved in a regular MDT meetings, work in an independent clinic, have guaranteed timetabled research time and a ring fenced study leave budget.

Gender differences in foot and ankle sporting injuries: A systematic literature review.

BACKGROUND: In response to the all-time high of female sports participation, there has been increasing scientific discourse and media interest in women's sporting injuries in recent years. In gender comparable sports the rate of foot and ankle injury for women is higher than for men. There are intrinsic and extrinsic factors which may explain this difference. METHODS: A systematic literature search was performed according to the PRISMA guidelines of PubMed, Ovid EMBASE and OVID MEDLINE. Relevant key terms were used to narrow the scope of the search prior to screening. Case reports, review articles, paediatric patients, non foot and ankle injuries and combat sports were excluded. We used dual author, two pass screening to arrive at final included studies. RESULTS: 2510 articles were screened after duplicate exclusion. 104 were included in this literature review. We identified lack of reporting gender difference in the literature.We identified that females have higher frequency and severity of injury. We provide an overview of our current understanding of ankle ligament complex injuries, stress fractures, ostochondral lesions of the talus and Achilles tendon rupture. We expand on the evidence of two codes of football, soccer and Australian rules, as a "case study" of how injury patterns differ between genders in the same sport. We identify gender specific characteristics including severity, types of injury, predisposing risk factors, anatomy, endocrinology and biomechanics associated with injuries. Finally, we examine the effect of level of competition on female injury patterns. CONCLUSIONS: There is a lack of scientific reporting of gender differences of foot and ankle injuries. Female athletes suffer foot and ankle injuries at higher rates and with greater severity compared to males. This is an under-reported, yet important area of orthopaedics and sports medicine to understand, and hence reduce the injury burden for female athletes.

Predictors of poor pre-operative patient reported outcome measures in elective foot and ankle surgery: Analysis of 1217 patients.

AIMS: Patient reported outcome measures (PROMs) have become the de facto measure of success in orthopaedic publications. It has been established that preoperatively collected patient reported outcomes correlate with post-operative outcome. The aim of our research is to identify which factors predict poor pre-operative scores using the most commonly used PROMs. METHODS: MOXFQ and EQ-5D scores were collected for all patients presenting for elective foot and ankle surgery over a four-year period from June 2018 to February 2022. Multivariate linear regression calculated associations between PROMs and demographics, diagnosis, pre-operative appointments and comorbidities. RESULTS: 1217 patients had PROMs taken, 1102 of these underwent a surgical procedure. Ankle and hindfoot arthritis predicted worse pre-operative scores. Total comorbidity number, depression/anxiety, younger patients, female gender and preoperative appointments with orthotist predicted a worse outcome score. CONCLUSION: Underlying patient characteristics can influence pre-operative PROMs in foot and ankle surgery.

Understanding the Offline Criminal Behavior of Individuals Who Live Stream Child Sexual Abuse.

Live streaming of child sexual abuse (CSA) involves the procurement and viewing of sexual abuse of children across the internet in real time, in exchange for money. These offenses leave little tangible evidence of the offense beyond a financial transaction, and metadata relating to the live-streaming session. This research analyzed the demographic, criminal history, and financial transaction characteristics of 209 individuals who live streamed child sexual abuse. A machine learning clustering technique was implemented to consider whether there were sub-groups present among these offenders, and in particular the prevalence of contact sexual offending among any detected sub-groups. Findings revealed that offenders tend to engage in live streaming around the same age, before making regular transactions with facilitators at brief intervals, with the majority of offenders featuring limited criminal history. This analysis identified a notable sub-group of live-streaming offenders that also engaged in contact sexual offending. This is the first study to empirically demonstrate an intersection between live streaming of CSA, and contact sexual offenses against children and adults. This research highlighted the importance of financial transactions data in detecting, and disrupting this crime type. Further, the identification of an intersection between live-streaming CSA offenders, and contact sexual offenders suggests that these individuals may pose a risk to both local and international communities.

Association of Preexisting Triple Fusion and Arthroscopic Ankle Arthrodesis nonunion.

BACKGROUND: Arthroscopic ankle arthrodesis (AAA) is a successful treatment for end-stage ankle arthritis. A significant early complication of AAA is symptomatic nonunion. Published nonunion rates range from 8% to 13%. Longer term, there is concern that it predisposes to subtalar joint (STJ) fusion. To better understand these risks, we undertook a retrospective investigation of primary AAA. METHODS: All adult AAA cases conducted at our institution over a 10-year period were reviewed. A total of 284 eligible AAA cases in 271 patients were analyzed. The primary outcome measure was radiographic union. Secondary outcome measures included reoperative rate, postoperative complications and subsequent STJ fusion. Univariate and multivariate logistic regression analysis was performed to identify nonunion risk factors. RESULTS: The overall nonunion rate was 7.7%. Smoking (odds ratio [OR] 4.76 [1.67, 13.6], P = .004) and previous triple fusion (OR 40.29 [9.46, 171.62], P < .001) were independent risk factors on univariate analysis. Only prior triple fusion persisted as a major risk factor associated with nonunion on multivariate analysis (OR 18.3 [3.4, 99.7], P < .001). Seventy percent of patients with a previous triple fusion went on to develop nonunion compared to 5.5% of those without. Increasing age, obesity, surgical grade, diabetes, postoperative weightbearing plan, steroid use, and inflammatory arthropathy were not significant risk factors. The leading cause of reoperation was hardware removal (18%). There were 5 superficial (1.8%) and 4 deep (1.4%) infections. Eleven (4.2%) required subsequent STJ fusion. The "survivorship" of STJ post AAA was 98%, 85%, and 74% at 2, 5, and 9 years, respectively. CONCLUSION: As the largest study of AAA in the literature, our findings suggest prior triple fusion is a major independent risk factor for AAA nonunion. These patients should be counseled of this high risk and may benefit from alternative surgical options. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

The Application and Patient-Reported Experience of Telephone Consultations in Elective Foot and Ankle Orthopaedic Surgery: 12-Month Follow-up.

BACKGROUND: Telemedicine offers convenient and affordable health care, overcoming the logistical challenges of face-to-face encounters. Clinicians increasingly relied on telemedicine during the global pandemic. To assess the ongoing role for telemedicine in orthopaedics, we prospectively analyzed the failure rate, safety and patient-reported experience of telephone consultations for 12 months. METHODS: 265 telephone Foot/Ankle consultations were conducted in April 2020 and were prospectively analyzed over 12 months. The primary outcome measure was the rate of failed telephone consultations. A consultation was deemed unacceptable if the patient did not answer, if the clinician could not reach a conclusion or if any outcome changed over 12 months. Secondary outcome measures included patient-reported satisfaction and time saved by avoiding a face-to-face visit. RESULTS: A clinical decision was reached in 84% of follow-up telephone consultations and 64% of new patient consultations (P = 0.001). Sixty-six percent were managed with nonoperative therapies, 16% were discharged, and 11% were added to the waiting list for surgery. The reasons for failing to achieve a clinical decision included failure to contact the patient (12.8%), inappropriate discharge with subsequent rereferral (1.9%), and insufficient clinical information (1.5%). Overall, 84.7% of patients reported that the telephone consultation was highly useful and 71.9% would recommend it to a friend or family member. Patients reported a mean time saving of 120 minutes. CONCLUSION: Based on our experience, we provide recommended criteria for the safe and practical use of telephone consultations and suggest versatile patient care pathways into which a telephone consultation can be incorporated. LEVEL OF EVIDENCE: Level IV, prospective cohort series (noncomparative).

Talar body fracture associated with unrecognised talocalcaneal coalition.

We report the case of a talar body fracture occurring in association with a previously undiagnosed talocalcaneal coalition. A rotational injury during a football tackle produced a grossly deformed ankle that was reduced in the emergency department. The unusual appearance of the medial sub-talar region on plain radiographs prompted further imaging by computerised tomography, which confirmed an osseous talocalcaneal coalition. Operative findings included a talar body fracture that could only be reduced after excision of the osseous coalition. The fracture was reduced and fixed. The patient made a good postoperative recovery with favourable AOFAS scores in the medium term at 1 year.

Multi-omic single cell analysis resolves novel stromal cell populations in healthy and diseased human tendon.

Tendinopathy accounts for over 30% of primary care consultations and represents a growing healthcare challenge in an active and increasingly ageing population. Recognising critical cells involved in tendinopathy is essential in developing therapeutics to meet this challenge. Tendon cells are heterogenous and sparsely distributed in a dense collagen matrix; limiting previous methods to investigate cell characteristics ex vivo. We applied next generation CITE-sequencing; combining surface proteomics with in-depth, unbiased gene expression analysis of > 6400 single cells ex vivo from 11 chronically tendinopathic and 8 healthy human tendons. Immunohistochemistry validated the single cell findings. For the first time we show that human tendon harbours at least five distinct COL1A1/2 expressing tenocyte populations in addition to endothelial cells, T-cells, and monocytes. These consist of KRT7/SCX+ cells expressing microfibril associated genes, PTX3+ cells co-expressing high levels of pro-inflammatory markers, APOD+ fibro-adipogenic progenitors, TPPP3/PRG4+ chondrogenic cells, and ITGA7+ smooth muscle-mesenchymal cells. Surface proteomic analysis identified markers by which these sub-classes could be isolated and targeted in future. Chronic tendinopathy was associated with increased expression of pro-inflammatory markers PTX3, CXCL1, CXCL6, CXCL8, and PDPN by microfibril associated tenocytes. Diseased endothelium had increased expression of chemokine and alarmin genes including IL33.

Increasing and decreasing motor and cognitive output: a model of general action and inaction goals.

General action and inaction goals can influence the amount of motor or cognitive output irrespective of the type of behavior in question, with the same stimuli producing trivial and important motor and cognitive manifestations normally viewed as parts of different systems. A series of experiments examined the effects of instilling general action and inaction goals using word primes, such as "action" and "rest." The first 5 experiments showed that the same stimuli influenced motor output, such as doodling on a piece of paper and eating, as well as cognitive output, such as recall and problem solving. The last 2 experiments supported the prediction that these diverse effects can result from the instigation of general action and inaction goals. Specifically, these last 2 studies confirmed that participants were motivated to achieve active or inactive states and that attaining them decreased the effects of the primes on behavior.

Congenital talipes equinovarus and congenital vertical talus secondary to sacral agenesis.

Sacral agenesis is a rare congenital defect which is associated with foot deformities such as congenital talipes equinovarus (CTEV) and less commonly congenital vertical talus (CVT). We report a 3-year-old Caucasian girl who was born with right CTEV and left CVT secondary to sacral agenesis. Her right foot was managed with a Ponseti casting method at 2 weeks, followed by an Achilles tenotomy at 4 months. The left foot was initially managed with a nocturnal dorsi-flexion splint. Both feet remained resistant and received open foot surgery at 10 months producing plantigrade feet with neutral hindfeet. At 19 months, she failed to achieve developmental milestones and examinations revealed abnormal lower limb reflexes. A full body MRI was performed which identified the sacral agenesis. We advocate early MRI of the spine to screen for spinal defects when presented with resistant foot deformities, especially when bilateral.

How Judgments Change Following Comparison of Current and Prior Information.

Although much observed judgment change is superficial and occurs without considering prior information, other forms of change also occur. Comparison between prior and new information about an issue may trigger change by influencing either or both the perceived strength and direction of the new information. In four experiments, participants formed and reported initial judgments of a policy based on favorable written information about it. Later, these participants read a second passage containing strong favorable or unfavorable information on the policy. Compared to control conditions, subtle and direct prompts to compare the initial and new information led to more judgment change in the direction of a second passage perceived to be strong. Mediation analyses indicated that comparison yielded greater perceived strength of the second passage, which in turn correlated positively with judgment change. Moreover, self-reports of comparison mediated the judgment change resulting from comparison prompts.

When the expectations from a message will not be realized: Naïve theories can eliminate expectation-congruent judgments via correction.

Research typically reveals that individuals like an object more when a persuasive message convinces them that this object is pleasant. In this paper, two experiments were conducted to understand the influence of such message-induced affective-expectations on judgments of experienced affect following direct encounter with an alcohol type of drink. As predicted, before trying the drink, recipients of the positive-expectation message had more positive expectations than recipients of the negative-expectation message. After drinking, participants judged the beverage to elicit affect congruent with message-induced expectations to the extent they did not endorse a naïve theory that their affective expectations congruently influence their experienced affect. In contrast, after drinking, the effect of the message disappeared when participants did endorse this naïve theory. Moderation of these effects, as well as theoretical and practical implications, are addressed.

Dissociated responses in the amygdala and orbitofrontal cortex to bottom-up and top-down components of emotional evaluation.

Although emotional responses to stimuli may be automatic, explicit evaluation of emotion is a voluntary act. These bottom-up and top-down processes may be supported by distinct neural systems. Previous studies reported bottom-up responses in the amygdala, top-down responses in the orbital and ventromedial prefrontal cortices, and top-down modulation of the amygdalar response. The current study used event-related fMRI on fifteen healthy males to examine these responses in the absence of stimulus anticipation or task repetition. Factorial analysis distinguished bottom-up responses in the amygdala from top-down responses in the orbitofrontal cortex. Activation of ventromedial prefrontal cortex and modulation of amygdalar response were not observed, and future studies may investigate whether these effects are contingent upon anticipation or cognitive set.