Risk factors for Midfoot arthritis associated with Medical history by Weight Bearing Computed Tomography.

Tarso-metatarsal joints and naviculocuneiform joints comprising midfoot is the second most commonly involved joints following the first metatarsophalangeal joint in the foot. However, related factors of midfoot arthritis (MA) have been rarely reported. The bony structure and alignment can be more precisely assessed using Weight-Bearing Computed Tomography (WBCT) than conventional radiographs. Therefore, the aim of this study was to investigate risk factors for MA related to medical history and comorbid foot deformities using WBCT. WBCT data from September 2014 to April 2022 were extracted from a single referral hospital. All cases were divided into two groups by the presence of MA. Twenty-five potential related factors including demographics, etiology, and common co-occurring foot deformities were collected for comparison. Six hundred six cases (247 males and 359 females) among consecutive 1316 cases between September 2014 to April 2022 were selected. One hundred thirty-nine male cases (56.3%) and 210 female cases (58.5%) showed MA. In stepwise multiple logistic regression analysis, 5 factors remained statistically significant. The multivariate-adjusted odds ratios for age, laterality, body mass index (BMI), Progressive Collapsing Foot Deformity (PCFD), and lesser toe deformities (LTD) were 1.08, 1.54, 1.05, 6.62, and 3.03 respectively. Risk factors for MA associated with medical history and foot deformities included age, laterality, BMI, PCFD, and LDT. Level of Evidence: Level III, retrospective case-control study.

Prevalence of midfoot arthritis and lesser toe deformities.

BACKGROUND: The aim of this study was to investigate the epidemiology of Midfoot Arthritis (MA) and Lesser toe deformity (LTD) using Weight-Bearing Computed Tomography (WBCT). METHODS: 606 cases (247 male, 359 female) among 1316 consecutive cases with WBCT data from September 2014 to April 2022 were retrospectively reviewed at a single referral institution. The Cochran-Armitage test was performed to evaluate the trend of prevalence with respect to age group and obesity classification. RESULTS: 139 male (56.3%) and 210 female cases (58.5%) showed MA. 157 male (63.6%) and 222 female cases (61.6%) showed LTD. 115 male (19.0%) and 157 female cases (25.9%) showed both MA and LTD. The prevalence of MA and LTD increased with age in both genders. The incidence of MA in males showed an increasing tendency until obesity class II and then was slightly decreased in obesity class III. This is contrary to females whose prevalence increased with increasing obesity groups. LTD had a similar pattern in both genders to obesity classification. CONCLUSIONS: The prevalence of MA and LTD increased with age and increasing obesity groups for both genders. LEVEL OF EVIDENCE: Level III, Retrospective Comparative Study.

The Role of the Transverse Arch in Progressive Collapsing Foot Deformity.

BACKGROUND: The transverse arch (TA) has recently been shown to significantly increase the intrinsic stiffness of the midfoot when coupled with the medial longitudinal arch (MLA). Progressive collapsing foot deformity (PCFD) is a complex deformity that ultimately results in a loss of stiffness and collapse of the MLA. The role of the TA has not been investigated in patients diagnosed with this disorder using weightbearing CT (WBCT). Therefore, this study aims to answer the following questions: (1) Is the curvature of the TA decreased in PCFD? (2) Where within the midfoot does TA curvature flattening happen in PCFD? METHODS: A retrospective review of weightbearing CT images was conducted for 32 PCFD and 32 control feet. The TA curvature was assessed both indirectly using previously described methods and directly using a novel measurement termed the transverse arch plantar (TAP) angle that assesses the angle formed between the first, second, and fifth metatarsals in the coronal plane. Location of TA collapse was also assessed in the coronal plane. RESULTS: The TAP angle was significantly higher in PCFD (mean 115.2 degrees, SD 10.7) than in the control group (mean 100.8 degrees, SD 7.9) (P < .001). No difference was found using the calculated normalized TA curvature between PCFD (mean 17.1, SD 4.8) and controls (mean 18.3, SD 4.0) (P = .266). Location of collapse along the TA in PCFD was most significant at the second metatarsal and medial cuneiform. CONCLUSION: The TA is more collapsed in PCFD compared to controls. This collapse was most substantial between the plantar medial cuneiform and the plantar second metatarsal. This may represent a location of uncoupling of the TA and MLA. LEVEL OF EVIDENCE: Level III, retrospective case control.

Relationship Between Obesity and Medial Longitudinal Arch Bowing.

BACKGROUND: There have been reports about the association between obesity and the medial longitudinal arch (MLA) of foot. The purpose of this study is to investigate the change of various parameters related to the MLA according to obesity classification severity by the World Health Organization using weightbearing computed tomography (WBCT). METHODS: WBCT data of the noninvolved side of patients presenting with unilateral foot and ankle problems or healthy candidates from September 2014 to October 2022 were extracted from a single referral hospital. Forty-four cases in each of 5 obesity classes were selected sequentially. Two orthopaedic surgeons measured foot and ankle offset, forefoot arch angle (FAA), hindfoot moment arm, percentage of uncoverage of the middle facet of the subtalar joint, talonavicular angle (TNA), navicular-medial cuneiform angle, medial cuneiform-first metatarsal angle, talus-first metatarsal angle (TMT1A), first tarsometatarsal subluxation (TMT1S), talonavicular coverage angle, navicular floor distance (NFD), and NFD per height. Positive values indicate plantar collapse. Intra- and interobserver reliabilities were assessed using intraclass correlation coefficients. One-way analysis of variance tests were performed for parametric data with equal variances, and Welch's test for unequal variances. Kruskal-Wallis test was performed for nonparametric data. Post hoc analysis was performed for statistically significant parameters. Correlation analysis between body mass index (BMI) and 12 parameters were performed using Pearson test. RESULTS: Intraobserver and interobserver reliability were excellent, except for TMT1S. The TNA and TMT1A showed a statistically significant difference. FAA (r = -0.2), TNA (r = 0.182), TMT1A (r = 0.296), and NFD (r = -0.173) showed a statistically significant correlation with BMI. CONCLUSION: In nonsymptomatic feet, we found that the talonavicular joint, as measured by the TNA, to be influenced by obesity classification. Obesity and increased BMI was associated with a negative influence on the MLA. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Deformities Influencing Different Classes in Progressive Collapsing Foot.

Background: The current classification system of progressive collapsing foot deformity (PCFD) is comprised of 5 possible classes. PCFD is understood to be a complex, three-dimensional deformity occurring in many regions along the foot and ankle. The question remains whether a deformity in one area impacts other areas. The objective of this study is to assess how each one of the classes is influenced by other classes by evaluating each associated angular measurement. We hypothesized that positive and linear correlations would occur for each class with at least one other class and that this influence would be high. Methods: We retrospectively assessed weight bearing CT (WBCT) measurements of 32 feet with PCFD diagnosis. The classes and their associated radiographic measurements were defined as follows: class A (hindfoot valgus) measured by the hindfoot moment arm (HMA), class B (midfoot abduction) measured by the talonavicular coverage angle (TNCA), class C (medial column instability) measured by Meary's angle, class D (peritalar sub-luxation) measured by the medial facet uncoverage (MFU), and class E (ankle valgus) measured using the talar tilt angle (TTA). Multivariate analyses were completed comparing each class measurement to the other classes. A p-value <0.05 was considered significant. Results: Class A showed substantial positive correlation with class C (ρ=0.71; R2=0.576; p=0.001). Class B was substantially correlated with class D (ρ=0.74; R2=0.613; p=0.001). Class C showed a substantial positive correlation with class A (ρ=0.71; R2=0.576; p=0.001) and class D (ρ=0.75; R2=0.559; p=0.001). Class D showed substantial positive correlation with class B and class C (ρ=0.74; R2=0.613; p=0.001), (ρ=0.75; R2=0.559; p=0.001) respectively. Class E did not show correlation with class B, C or D (ρ=0.24; R2=0.074; p=0.059), (ρ=0.17; R2=0.071; p=0.179), and (ρ=0.22; R2=0.022; p=0.082) respectively. Conclusion: This study was able to find relations between components of PCFD deformity with exception of ankle valgus (Class E). Measurements associated with each class were influenced by others, and in some instances with pronounced strength. The presented data may support the notion that PCFD is a three-dimensional complex deformity and suggests a possible relation among its ostensibly independent features. Level of Evidence: III.

Prevalence and Risk Factors of Poor Sleep Quality in Collegiate Athletes during COVID-19 Pandemic: A Cross-Sectional Study.

The COVID-19 pandemic has changed our lifestyle, sleep and physical activity habits. This study evaluated the prevalence of poor sleep quality, its disrupters, and the impact of the pandemic in collegiate athletes. We performed a cross-sectional study of collegiate athletes (N = 339, median age: 20 (IQR,19−21) years old, 48.5% female, 47% individual sports) who received a web-based questionnaire in April 2021. This survey included subject characteristics, chronotype, sleep disrupters, the changes due to the pandemic and sleep quality (Pittsburg Sleep Quality Index [PSQI]). A multivariate linear regression was performed to assess the relationship between sleep quality, gender, chronotype, sleep disrupters and the changes to training volume or sleep. Results showed a disrupted sleep quality in 63.7%. One in five students had a total sleep time under 6.5 h per night. Poor sleep quality was significantly correlated with nocturnal concerns related to the pandemic, evening chronotype, female gender, third year of study, caffeine consumption and lack of sleep routine (all p < 0.05). To conclude, poor sleep quality is common in collegiate athletes. Sleep disrupters remain prevalent in the lifestyle habits of this population and may have been exacerbated by changes related to the COVID-19 pandemic. Sleep hygiene should become a major aspect of sports education during the return to post-covid normality.

Does tibialis posterior dysfunction correlate with a worse radiographic overall alignment in progressive collapsing foot deformity? A retrospective study.

BACKGROUND: Posterior Tibial Tendon (PTT) dysfunction is considered to have an important role in Progressive Collapsing Foot Deformity (PCFD). The objective of our study was to assess the relationship between PTT status and three-dimensional foot deformity in PCFD. METHODS: Records from 25 patients with PCFD were included for analysis. The PTT was considered deficient in patients with a positive single heel rise test or a deficit in inversion strength. Three-dimensional foot deformity was assessed using the Foot and Ankle Offset (FAO) from Weight-Bearing-CT imaging. Hindfoot valgus, midfoot abduction and medial longitudinal arch collapse were assessed on X-Rays using hindfoot moment arm, talonavicular coverage angle and Meary's angle respectively. Deland and Rosenberg MRI classifications were used to classify PTT degeneration. RESULTS: PCFD with PTT deficit (13/25) had a mean FAO of 7.75 + /- 3.8% whereas PCFD without PTT deficit had a mean FAO of 6.68 + /- 3.9% (p = 0.49). No significant difference was found between these groups on the hindfoot moment arm and the talonavicular coverage angle (respectively p = 0.54 and 0.32), whereas the Meary's angle was significantly higher in case of PCFD with PTT deficit (p = 0.037). No significant association was found between PTT degeneration on MRI and FAO. CONCLUSION: PCFD associated three-dimensional deformity, hindfoot valgus and midfoot abduction were not associated with PTT dysfunction. PTT dysfunction was only associated with a worse medial longitudinal arch collapse in our study. Considering our results, it does not appear that PTT is the main contributor to PCFD. LEVEL OF EVIDENCE: Level III, Retrospective Comparative Study.

Flexor tenodesis procedure in the treatment of lesser toe deformities.

In this technical report study, we describe the use of a flexor tenodesis procedure in the treatment of lesser toe deformities (LTD). Using a specific implant, both the flexor digitorum longus and brevis tendons are attached to the plantar aspect of the proximal phalanx, allowing dynamic correction of flexible deformities of metatarsophalangeal and interphalangeal joints. Good clinical results and absence of complications were observed in a series of 3 patients, with considerable correction of the LTD, and absence of substantial residual floating toe or metatarsophalangeal joint stiffness. LEVEL OF EVIDENCE: V - Technical Report/Case Report/Expert Opinion.

Weightbearing Computed Tomography for Assessment of Foot and Ankle Deformities: The Iowa Experience.

BACKGROUND: Weightbearing computed tomography (WBCT) is a reliable and precise modality for the measurement and analysis of bone position in the foot and ankle, as well as associated deformities. WBCT to assess three dimensional relationships among bones allowed the development of new measurements, as the Foot and Ankle Offset (FAO), which has high inter and intra-rater reliability. This study reports the University of Iowa's experience utilizing WBCT for the care of foot and ankle patients by describing its utility across different orthopedic diseases in improving diagnostic assessment, aiding surgical planning, and expanding the use for objective clinical follow-up. METHODS: The medical records of consecutive patients with various foot and ankle disorders that underwent WBCT examination as part of the standard of care at a single institution between November 2014 and August 2020 were retrospectively reviewed. Patient factors, including body mass index (BMI), sex, and patient comorbidities were collected. 3D coordinates for calculation of FAO were harvested using the Multiplanar Reconstruction (MPR) views were calculated from the obtained exams. Descriptive statistics were performed with Shapiro-Wilk test and the Anderson-Darling tests. RESULTS: 1175 feet and ankles (820 patients) had a WBCT performed over the studied 68 months. 53% of the subjects were male and 47% female. 588 of the acquisitions were from the right side (50.04%) and 587 from the left side (49.96%). Diabetes was present in 15.47% of, Rheumatic diagnoses in 4.52% and smoking habits in 44.10% of patients. Mean BMI of the sample was found to be 32.47 (32.03-32.90, 95% CI). The mean Foot and Ankle Offset (FAO) encountered in the study's population was 2.43 (2.05-2.82, 95% CI; min -30.8, max 37.65; median 2.39). CONCLUSION: This study contains the largest cohort of WBCTs with accompanied FAO measurements to date, which can aid with establishing a new baseline FAO measurement for multiple pathological conditions. Acquiring WBCTs resulted in a variety of more specific diagnoses for patient with foot and ankle complaints. The ability to utilize WBCT for presurgical planning, the capability to provide a 3D reconstruction of patient anatomy, and its use for assessment of advanced relational foot and ankle measurements, such as FAO, demonstrate how WBCT may serve as a remarkable utility in clinical practice and has become a standard of care in our practice at the University of Iowa.Level of Evidence: IV.

The Rotational Positioning of the Bones in the Medial Column of the Foot: A Weightbearing CT Analysis.

BACKGROUND: Malrotation of medial column bones of the foot has been advocated as an important factor in foot conditions such as hallux valgus and progressive collapsing foot deformity. Although stated as a deformity component, variances of normality in the general population are not completely understood. This study intended to describe the rotational profile of all medial column bones using weightbearing computed tomography (WBCT) images in a cohort of patients with different foot and ankle problems. METHODS: In this retrospective study, 110 feet of 95 consecutive patients that received a WBCT for assessment of different foot and ankle pathologies were included. Measurements were performed by a blinded fellowship-trained orthopedic foot and ankle surgeon. Rotation of the navicular, medial cuneiform, proximal and distal first metatarsal as well as proximal phalanx of the first toe were recorded. Positive values were considered pronation and negative values were considered supination. Rotational profile of each bone/ segment was assessed by ANOVA and comparison between each segment was performed using Wilcoxon Each-Pair analysis. P-values of less than 0.05 were considered significant. RESULTS: On average, a rotational positioning in pronation (internal rotation) was observed for all medial column bones. The navicular (43.2°, CI 41.1°-45.3°) and the proximal metatarsal (33.9°, CI 31.8°-36.0°) showed the highest mean rotation values. The medial cuneiform presented the lowest mean pronation (6.1°, CI 4.0°-8.3°). Comparison between each bone segment demonstrated statistically significant differences of rotational alignment for the different bones (p<0.0001), with the exception of the distal metatarsal and proximal phalanx, that had similar amounts of pronation. A zig-zag rotational pattern of alignment was observed from proximal to distal, with relative supination/pronation of adjacent medial column bones. CONCLUSION: The overall rotational profile of medial column bones was found to be in absolute pronation, most pronounced at the navicular and proximal first metatarsal, with significant differences in the amount of pronation when comparing most of the medial column bones. The presented data may be utilized as reference/ baseline values of medial column rotation, supporting future prospective, comparative and controlled studies.Level of Evidence: IV.

What Are the Updates on Epidemiology of Progressive Collapsing Foot Deformity?

Progressive collapsing foot deformity is one of the most controversial topics in foot and ankle surgery. Much research has been done regarding anatomy, biomechanics, and etiology behind this complex deformity and there is interest in studying metabolic or genetic conditions that could influence the development of this multifactorial disorder. Relevant anatomy includes osseous and soft tissue structures. Several risk factors like obesity, genetics, and flat foot during childhood have been proposed in literature. It occurs 3 times more often in women, the peak incidence happening at age 55, and is more common in white, obese, diabetic, rheumatic, and hypertensive patients.

Correlation between indirect radiographic parameters of first metatarsal rotation in hallux valgus and values on weight-bearing computed tomography.

PURPOSE: To verify if indirect radiographic signs of first metatarsal pronation, determined by the head round sign, correspond to weight-bearing computed tomography (WBCT) measurements. METHODS: In this case-control retrospective study, we analyzed 26 hallux valgus (HV) feet and 20 controls through conventional radiograph (CR) and WBCT images. Two blinded orthopaedic foot and ankle surgeons performed the measurements. Pronation classification (head roundness), head diameter (HD), traditional HV angles, arthritis, sesamoid positioning, and first metatarsal rotation angle (MRA) (alpha angle) were evaluated. Comparisons were performed by Student's T-test and a multivariate regression was executed. P-values less than 0.05 were considered significant. RESULTS: Mean values were higher in HV patients than controls when evaluating MRA (11.51 [9.42-13.60] to 4.23 [1.84-6.62], 95%CI), HD (22.35 [21.52-23.18] to 21.01 [20.07-21.96]), and sesamoid rotation angle (SRA) (26.72 [24.09-29.34] to 4.56 [1.63-7.50]). The MRA had a low influence in head roundness classification (R2: 0.15). Changes in the pronation classification were explained chiefly by the sesamoid station (SS) (R2: 0.37), where stations 4 to 7 were found to be strong predictors of roundness classifications 2 and 3. CONCLUSION: Indirect signs of metatarsal pronation, determined by the head round sign, correlate weakly with the alpha angle measured in WBCT. The presence of arthritis and sesamoids displacement might modify the perception of first head roundness. The influence of MRA in the classification was low, where SS from 4 to 7 was strong predictors of a higher pronation classification.

Sports-Related Lisfranc Injuries and Recognition of Lisfranc Variants: Surgical Strategies for Stabilization.

Much has changed since Lisfranc described lesions at the tarsometatarsal (TMT) joint in 1815. What was considered an osseous high-energy condition nowadays is understood as myriad possible presentations, occurring in minor and inconspicuous traumas. Advancements in diagnostics of Lisfranc injury allow recognizing many variants of this trauma presentation, most of them with a focus on ligaments. This perception shifted trends in surgical planning, especially for implants and fixation techniques. These revolutions established a new and evolving universe around TMT lesions, different from what was known only a few years ago and still not enough to completely settle the disease scenario.

The Effect of Improving Basic Preventive Measures in the Perioperative Arena on Staphylococcus aureus Transmission and Surgical Site Infections: A Randomized Clinical Trial.

Importance: Surgical site infections increase patient morbidity and health care costs. The Centers for Disease Control and Prevention emphasize improved basic preventive measures to reduce bacterial transmission and infections among patients undergoing surgery. Objective: To assess whether improved basic preventive measures can reduce perioperative Staphylococcus aureus transmission and surgical site infections. Design, Setting, and Participants: This randomized clinical trial was conducted from September 20, 2018, to September 20, 2019, among 19 surgeons and their 236 associated patients at a major academic medical center with a 60-day follow-up period. Participants were a random sample of adult patients undergoing orthopedic total joint, orthopedic spine, oncologic gynecological, thoracic, general, colorectal, open vascular, plastic, or open urological surgery requiring general or regional anesthesia. Surgeons and their associated patients were randomized 1:1 via a random number generator to treatment group or to usual care. Observers were masked to patient groupings during assessment of outcome measures. Interventions: Sustained improvements in perioperative hand hygiene, vascular care, environmental cleaning, and patient decolonization efforts. Main Outcomes and Measures: Perioperative S aureus transmission assessed by the number of isolates transmitted and the incidence of transmission among patient care units (primary) and the incidence of surgical site infections (secondary). Results: Of 236 patients (156 [66.1%] women; mean [SD] age, 57 [15] years), 106 (44.9%) and 130 (55.1%) were allocated to the treatment and control groups, respectively, received the intended treatment, and were analyzed for the primary outcome. Compared with the control group, the treatment group had a reduced mean (SD) number of transmitted perioperative S aureus isolates (1.25 [2.11] vs 0.47 [1.13]; P = .002). Treatment reduced the incidence of S aureus transmission (incidence risk ratio; 0.56; 95% CI, 0.37-0.86; P = .008; with robust variance clustering by surgeon: 95% CI, 0.42-0.76; P < .001). Overall, 11 patients (4.7%) experienced surgical site infections, 10 (7.7%) in the control group and 1 (0.9%) in the treatment group. Transmission was associated with an increased risk of surgical site infection (8 of 73 patients [11.0%] with transmission vs 3 of 163 [1.8%] without; risk ratio, 5.95; 95% CI, 1.62-21.86; P = .007). Treatment reduced the risk of surgical site infection (hazard ratio, 0.12; 95% CI, 0.02-0.92; P = .04; with clustering by surgeon: 95% CI, 0.03-0.51; P = .004). Conclusions and Relevance: Improved basic preventive measures in the perioperative arena can reduce S aureus transmission and surgical site infections. Trial Registration: ClinicalTrials.gov Identifier: NCT03638947.

Assessment of anesthesia machine redesign on cleaning of the anesthesia machine using surface disinfection wipes.

BACKGROUND: The use of surface disinfection wipes after induction of anesthesia improves anesthesia machine cleaning. We assessed whether anesthesia machine surface redesign improves disinfection wipe cleaning by anesthesia residents. METHODS: Sixteen anesthesia residents were assigned to 2 cases in series. The first case was randomly assigned to regional knee or hip surgery, a brief or detailed checklist, and the Perseus A500 (redesigned) or GE Aespire 7900 (conventional) machine. The second case was assigned to the opposite for each condition. Setup checklists included cleaning instructions. Eight machine sites representing redesign were contaminated with fluorescent gel prior to setup and reassessed after setup to assess cleaning efficacy. Cleaning was compared by fluorescence quantification of before and after setup images. Our primary hypothesis was that, overall, more sites would be cleaned on the Perseus machine. Our secondary hypothesis was that redesign would affect some sites. RESULTS: Overall, the number of sites cleaned did not differ between machines (median 0.74 more sites out of 8 for the Perseus A500; 25th and 75th percentiles, -0.34 and 1.04; P = .093). However, greater cleaning was observed for the work surface and manual bag arm/hose of the Perseus machine (0.58 more sites out of 2; 25th and 75th percentiles, 0.35 and 1.05; P = .0004). CONCLUSIONS: The number of sites cleaned overall did not differ between the conventional and redesigned Perseus A500 machines. However, the redesigned work surface and smooth manual bag arm features improved resident cleaning with surface disinfection wipes.