Total Knee Arthroplasty in the Valgus Knee.

An estimated 10 to 15% of total knee arthroplasties (TKAs) are implanted for a diagnosis of arthritis when a valgus deformity is present. There are various techniques and considerations that must be considered for a successful TKA in a patient with a valgus deformity. This article provides a detailed summary of the anatomy, pathology, bone preparation, soft tissue management, implant selection, and complications when performing a TKA in a patient with valgus deformity.

Achieving Correct Balance in Total Knee Arthroplasty with Fixed Varus Deformity.

Varus knee deformity is one of the most common deformities presenting for total knee arthroplasty (TKA). When present, a varus knee deformity contributes to overload of the medial joint compartment during gait, leading to increased medial compartment forces as well as lateral soft tissue lengthening. Additionally, a fixed varus deformity is associated with medial soft tissue contractures of the deep and superficial medial collateral ligament (MCL) and posteromedial capsule. With a fixed varus deformity, soft tissue releases may be necessary to create equivalent and rectangular flexion and extension gaps. There may also be anteromedial tibial bone defects, medial femoral condyle defects, and occasionally flexion contractures, especially in more severe cases. In cases of severe varus deformity with medial tibial bone loss, bone defects must be addressed to ensure adequate implant support. In many cases, a primary knee implant can be utilized in cases of varus knee deformity, but occasionally prostheses with higher levels of constraint may be required to balance and stabilize the knee. TKA has had a successful track record, with high levels of long-term implant survivorship even in cases of severe varus. Iatrogenic MCL instability and tibial aseptic loosening are complications associated with TKA in cases of severe varus, and multiple methods to avoid complications are presented here.

Remote Patient Monitoring Following Total Joint Arthroplasty.

This review article presents the current state of remote patient monitoring (RPM) in total joint arthroplasty. RPM refers to the use of telecommunication with wearable and implantable technology to assess and treat patients. Several forms of RPM are discussed including telemedicine, patient engagement platforms, wearable devices, and implantable devices. The benefits to patients and physicians are discussed in the context of postoperative monitoring. Insurance coverage and reimbursement of these technologies are reviewed.

Classifying Bone Loss in Failed Stemmed Total Knee Arthroplasty: Determining Reliability.

BACKGROUND: Failed stemmed total knee arthroplasty (TKA) components present with varying degrees of bone loss and technical challenges. A classification system has been proposed based upon metaphyseal bone loss and diaphyseal cortical integrity. A validation study was performed to determine interobserver and intraobserver reliability at multiple institutions and with different levels of training. METHODS: An online survey with digital anteroposterior and lateral radiographs was sent to 5 arthroplasty surgeons and 5 adult reconstruction fellows. The survey included 62 cases with stemmed femoral and tibial components, considered failures and pending revision, and scored by each reviewer independently using the classification system. Each case was scored in 2 separate sessions. Interobserver and intraobserver reliability was assessed using the intraclass correlation coefficient (ICC). RESULTS: Interobserver grading for both the femur (0.69) and tibia (0.72) showed strong reliability among the attendings and fellows, with slightly stronger reliability in tibia cases. The intraclass correlation coefficient (ICC) for attendings and fellows was similar overall, demonstrating consistency of the grading regardless of training level. Intraobserver comparisons showed a strong ICC for attendings and fellows in femoral cases, while fellows had near-perfect ICC in tibia cases. Across all reviewers there was on average 93% agreement within 1 grade per case with the majority of the discrepancy occurring at the metaphyseal-diaphyseal junction. CONCLUSION: This classification demonstrated overall strong interobserver and intraobserver reliability, with 93% agreement within 1 grade of bone loss. With further education, this classification system can ultimately be used to standardize the degree of bone loss in failed stemmed components and help with preoperative planning.

Classification of Bone Loss With Failed Stemmed Components in Revision Total Knee Arthroplasty.

INTRODUCTION: With the increasing number of primary total knee arthroplasties (TKA) being performed annually there is also an expected increase in the number of revision TKA, as well as failed revision TKA with stemmed components. A new classification system based upon the location and degree of bone loss in the tibial and or femoral metaphysis and diaphysis is proposed. Type 1 has no bone loss in the metaphysis and diaphysis; Type 2 has a metaphyseal bone loss. Type 3 defects are subdivided into A and B, depending on the extent of the diaphyseal bone loss. Type 4 has extensive bone loss with an expansion of the diaphyseal cortex. METHOD: An online survey with digital anteroposterior and lateral radiographs was sent to five arthroplasty surgeons. A total of 55 cases with stemmed femoral and tibial components, considered failures and pending revision, were reviewed. By using the proposed classification system, each femoral and tibial component was scored. Interobserver reliability was determined using the intraclass correlation coefficient for pooled data. RESULTS: Comparisons between each individual reviewer demonstrated moderate to strong agreement overall for the reviewers using the classification, with an average correlation coefficient of 0.67 (95% CI [0.57 to 0.77]) for all cases, signifying a low variation in the scores of each case. Looking specifically at the femoral components, the ICC was 0.62 (95% CI [0.477 to 0.76]), while the ICC for the tibial components was 0.71 (95% CI [0.58 to 0.83]). DISCUSSION: This classification, which has demonstrated moderate to strong interobserver reliability, can help surgeons determine the degree of anticipated bone loss and approach these complex cases with a preoperative plan based upon the radiographic images. This classification system will also allow standardized communication among surgeons, categorization of procedures for comparative research, and anticipated prognosis.

Complications of Hardware Removal.

BACKGROUND: While hardware removal may improve patient function, the procedure carries risks of unexpected outcomes. Despite being among the most commonly performed orthopaedic procedures, scant attention has been given to its complication profile. METHODS: We queried the American Board of Orthopaedic Surgery (ABOS) de-identified database of Part II surgical case lists from 2013 through 2019 for American Medical Association Current Procedural Terminology (CPT) implant-removal codes (20680, 20670, 22850, 22852, 22855, 26320). Hardware removal procedures that were performed without any other concurrent procedure ("HR-only procedures") were examined for associated complications. RESULTS: In the 7 years analyzed, 13,089 HR-only procedures were performed, representing 2.1% (95% confidence interval [CI], 2.1% to 2.2%) of the total of 609,150 surgical procedures during that period. A complication was reported to have occurred in association with 1,256 procedures (9.6% [95% CI, 9.1% to 10.1%]), with surgical complications reported in association with 1,151 procedures (8.8% [95% CI, 8.3% to 9.3%]) and medical/anesthetic complications reported in association with 196 procedures (1.5% [95% CI, 1.3% to 1.7%]). Wound-healing delay/failure (2.1% [95% CI, 1.8% to 2.3%]) and infection (1.6% [95% CI, 1.4% to 1.8%]) were among the most commonly reported complications after HR-only procedures, but other serious events were reported as well, including unexpected reoperations (2.5% [95% CI, 2.2% to 2.7%]), unexpected readmissions (1.6% [95% CI, 1.4% to 1.8%]), continuing pain (95% CI, 1.2% [1.0% to 1.4%]), nerve injury (0.6% [95% CI, 0.4% to 0.7%]), bone fracture (0.5% [95% CI, 0.4% to 0.6%]), and life-threatening complications (0.4% [95% CI, 0.3% to 0.5%]). CONCLUSIONS: Hardware removal is one of the most commonly performed orthopaedic procedures and was associated with an overall complication rate of 9.6% (95% CI, 9.1% to 10.1%) in a cohort of recently trained orthopaedic surgeons in the United States. Although specific complications such as infection, refractures, and nerve damage were reported to have relatively low rates of occurrence, and associated life-threatening complications occurred rarely, surgeons and patients should be aware that hardware removal carries a definite risk. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Reliability of measurements assessing the Lisfranc joint using weightbearing computed tomography imaging.

INTRODUCTION: Subtle Lisfranc joint injuries remain challenging to diagnose in clinical practice. Although of questionable accuracy, bilateral weightbearing radiographs are considered the current gold standard to assess these injuries. However, weightbearing computed tomography (WBCT), which provides clearer visualization of bony landmarks, can also be used for evaluation. This study aims to design a protocol that reliably measures the distance between the medial cuneiform (C1) and second metatarsal (M2) to assess the Lisfranc joint using WBCT imaging. METHODS: Two unique methods of measuring the C1-M2 distance were designed that localize the center of the interosseous Lisfranc ligament (ILL, reference point). This reference point was located by (I) measuring a specific distance at the M2 base, or (II) approximating from nearby bony landmarks, on both axial (Ax) and coronal (Cor) WBCT images. Four parameters (I-Ax, I-Cor, II-Ax, and II-Cor) were evaluated for each of 96 specimens. Measurements were recorded by three independent observers and repeated for inter- and intra-observer agreement. RESULTS: In total, 96 patient image series were included and assessed in our study with an average age of 46 (19-66, SD 16.1) and average BMI of 25.8 (17.8-30.5, SD 4.3). I-Ax showed excellent agreement for intra-observer evaluation (R = 0.802) and good agreement for inter-observer evaluation (R = 0.727). I-Cor demonstrated excellent inter- (R = 0.814) and intra-observer (R = 0.840) agreement. Good agreement was found for both II-Ax and II-Cor for both intra- (R = 0.730, R = 0.708) and inter-observer (R = 0.705, R = 0.645) evaluation. CONCLUSION: Measuring the C1-M2 joint space with coronal WBCT imaging through a protocol that localizes the ILL is reproducible, simple, and can potentially be utilized clinically to evaluate the Lisfranc joint.

Social Media Utilization Among Shoulder and Elbow Surgeons.

INTRODUCTION: Social media represents a novel platform for patient-physician interaction. Although social media utilization patterns have been analyzed in other fields, no such study has been performed in shoulder and elbow specialists. METHODS: The membership database of the society of the American Shoulder and Elbow Surgeons was queried. Online searches were performed to identify if each surgeon had professional profiles on popular social media platforms. A social media score was then calculated, defined as the number of active accounts. Statistical analysis was used to test for associations between demographics and social media utilization. RESULTS: Six hundred seventy-six surgeons were analyzed. The average social media score was 1.61. The most highly used platform was LinkedIn (61%). The least used platform was Instagram (5% active, 11% total). Female surgeons were more likely to use Instagram than men (12.5% versus 4.9%). Academic surgeons were more likely to use ResearchGate (46.5% versus 33.3%), whereas private practice surgeons were more likely to have a website (19.9% versus 11.7%). Practitioners from the South had the lowest social media utilization. CONCLUSIONS: Shoulder and elbow surgeons underuse social media. As the influence of social media continues to grow, it will be important for surgeons to implement social media within their practices.

Change in the First Cuneiform-Second Metatarsal Distance After Simulated Ligamentous Lisfranc Injury Evaluated by Weightbearing CT Scans.

BACKGROUND: This study aimed to investigate the widening between the first cuneiform (C1) and second metatarsal (M2) in a Lisfranc ligamentous complex (LLC) joint injury model subjected to successive ligament dissections evaluated by weightbearing computed tomography (CT) scans. METHODS: Twenty-four intact cadaveric feet served as the control (condition 1). Each component of the LLC (dorsal, interosseous, and plantar ligaments-conditions 2, 3, and 4, respectively) were then sequentially dissected. The specimens were equally randomized to 1 of 3 additional dissections (first or second tarsometatarsal [TMT] joint capsule or first-second intercuneiform ligament [ICL]-conditions 5a, 5b, and 5c, respectively). One additional ligament was then randomly transected (eg, condition 6ac-transection of the first TMT capsule and ICL). Finally, the remaining ligament was transected (condition 7). After each dissection, CT scans were acquired under nonweightbearing (NWB, 0 kg), partial-weightbearing (PWB, 40 kg), and full-weightbearing (FWB, 80 kg) conditions. The distance between the lateral border of C1 and the medial border of M2 was assessed to evaluate diastasis. Linear regressions with 95% CIs and converted q values were used to compare the measured data. RESULTS: No significant differences were found within the control. In condition 4, an average axial plane widening relative to control of 1.6 mm (95% CI, 1.5-1.8) and 2.1 mm (95% CI, 1.9-2.2) was observed under PWB and FWB. A coronal plane widening of 1.5 mm (95% CI, 1.3-1.6) and 1.9 mm (95% CI, 1.7-2.1) under PWB and FWB, respectively, was measured. A 95% CI of at least a 2-mm widening during PWB was demonstrated in 5c, 6ac, 6bc, and 7. CONCLUSIONS: Weightbearing computed tomography (WBCT) scans were used to detect ligamentous Lisfranc injuries in a cadaveric model. Relative axial widening greater than 1.5 mm under PWB conditions could indicate a complete LLC injury. Complete transection of the intercuneiform 1-2 ligament was required to detect a 2-mm widening in the nonweightbearing condition. CLINICAL RELEVANCE: This study provides insight on the detection of various severities of LLC injuries using WBCT imaging.

Comparison of External Torque to Axial Loading in Detecting 3-Dimensional Displacement of Syndesmotic Ankle Injuries.

BACKGROUND: Current imaging techniques try to quantify 3-dimensional displacement of syndesmotic ankle injuries using 2-dimensional measurements, which may obscure an exact diagnosis. Therefore, our aim was to determine 3-dimensional displacement of syndesmotic ankle injuries under load and torque using a weightbearing computed tomography (WBCT) and to assess the relation with previously established 2-dimensional measurements. METHODS: Seven paired cadaver specimens were mounted into a radiolucent frame. WBCT scans were obtained to generate 3-dimensional models after different patterns of axial load (0 kg, 85 kg) combined with external torque (0, 10 Nm). Sequential imaging was repeated in ankles containing intact syndesmotic ligaments, sectioning of the anterior inferior tibiofibular ligament (AITFL; condition 1A), deltoid ligament (DL; condition 1B), combined AITFL+DL (condition 2), and AITFl+DL+interosseous membrane (condition 3). Reference anatomical landmarks were established relative to the intact position of the fibula to quantify displacement. A subsequent correlation analysis was performed between the obtained 2- and 3-dimensional measurements. RESULTS: Axial load increased lateral translation (mean = -0.9 mm, 95% confidence interval [CI]: 1.3, -0.1) significantly in condition 2 relative to the intact ankle (P < .05) but did not demonstrate other significant displacements. External torque increased displacement significantly in all directions (P < .05), except for dorsal translation of the fibula (P > .05). The highest displacement could be detected when external torque was applied in condition 3 and consisted of posterior translation (mean = -3.1 mm; 95% CI: -4.8, -2.7) and external rotation (mean = -4.7 degrees; 95% CI: -5.6, -2.9). Pearson correlation coefficients between the 2-dimensional and 3-dimensional measurements were moderate and ranged from 0.31 to 0.56 (P < .05). CONCLUSION: External torque demonstrated superiority over axial load in detecting syndesmotic ankle instability. Axial load increased lateral translation; however, differences were submillimeter in magnitude until torque was applied. A moderate correlation was found with previously established 2-dimensional measurements. CLINICAL RELEVANCE: In clinical practice these findings substantiate application of external torque in current imaging modalities to improve detection of syndesmotic ankle injuries.

Relationship of Press Ganey Satisfaction and PROMIS Function and Pain in Foot and Ankle Patients.

BACKGROUND: Patient satisfaction has garnered interest as a tool to measure health care quality. However, orthopedic studies in total joint arthroplasty, spine, and hand patients have offered conflicting relationships between Press Ganey (PG) satisfaction metrics and patient-reported outcome (PRO) measures. No prior study has assessed the relationship between PG and PROs in foot and ankle patients. Whether satisfaction and outcomes instruments, though, measure similar or differing aspects of the patient experience is unclear. Here, we tested if there was an association between Patient-Reported Outcomes Measurement Information System (PROMIS) outcomes and PG satisfaction scores. METHODS: PG and PROMIS outcomes data for new patient visits to an orthopedic foot and ankle clinic between 2015 and 2017 were retrospectively analyzed. Patients that completed PG satisfaction surveys were included for study. All patients who completed PG surveys and completed one or both PROMIS physical function (PF) or pain interference (PI) metrics administered by computerized adaptive testing were included. Negative binomial regressions were used to compare PRO scores to PG overall satisfaction and PG satisfaction with care provider, adjusting for patient characteristics. Results were reported as dissatisfaction score ratios, which represented the amount of PG dissatisfaction associated with a 10-point increase in PROMIS PF or PI. Of the 3984 new patient visits, only 441 completed the PG survey (11.3% response rate). RESULTS: Ceiling effects were seen with PG data: 64% of patients reported perfect satisfaction with care provider and 27% had perfect overall satisfaction. Higher function on the PROMIS PF was weakly associated with increased overall satisfaction (ratio = 0.82, 95% CI: 0.68-0.99, P = .039) and increased satisfaction with care provider (ratio = 0.60, 95% CI: 0.40-0.92, P = .019). However, pain (PROMIS PI) was not associated with overall satisfaction or with satisfaction with care provider. CONCLUSIONS: Based on our data here, patient satisfaction was weakly related to patient-reported function but not pain interference among this subset of new patients presenting to a foot and ankle clinic. Given our essentially negative findings, further study is needed to determine which aspects of the PG satisfaction and PROMIS scores track similarly. Further, our findings add to the growing literature showcasing limitations of the PG tool, including low response rates and notable ceiling effects. If satisfaction metrics and patient-reported outcomes capture differing aspects of the patient experience, we need to better understand how that influences the measurement of health care quality and value. LEVEL OF EVIDENCE: Level III, comparative study.

Surgical outcome of chronic Lisfranc injury without secondary degenerative arthritis: A systematic literature review✰.

BACKGROUND: Chronic Lisfranc joint injuries (tarsometatarsal, TMT) can present as a variety of clinical symptoms and radiographic findings. If significant arthritis at the Lisfranc joint is present, salvage arthrodesis is an option. For patients who receive a delayed diagnosis and/or present with no signs of arthritic changes, selecting the most appropriate treatment can be challenging. This article provides a systematic review of current surgical treatment options and outcomes for patients with a chronic Lisfranc injury but no secondary degenerative changes. METHODS: Four major medical databases were searched from inception through March 5, 2019: PubMed, Science Direct, Scopus, and Embase. Studies were included if they were original research studies that assessed the outcome of patients treated surgically for chronic Lisfranc injuries without secondary osteoarthritic changes. Only studies written in English and German were considered. The following data were recorded from each study: number of patients and feet included, study design (prospective vs. retrospective, single vs. multicenter, level of evidence), time between initial injury and operation, operative techniques, age, mechanism of injury, type of injury (purely ligamentous or ligamentous with concomitant bony fractures), indications for surgery, pre-operative assessment, postoperative follow-up time, time to return to activity or sport, and clinical outcome. The modified Coleman Score was used to assess the methodologic quality of the included studies. RESULTS: Of the 6,845 screened, ten studies met the above criteria and were included. All but one were single center studies. All studies were either retrospective or prospective case series. Overall, studies generally reported low complication rates and good functional outcomes. Postoperative outcomes were most frequently measured with the American Orthopaedic Foot and Ankle (AOFAS) score; the overall mean preoperative AOFAS scores of 55.7 significantly improved to 88.1 at final follow-up. CONCLUSIONS: No definitive consensus exists on how Lisfranc instability without concurrent osteoarthritis should be surgically managed. Despite the delay in diagnosis, patients who undergo surgical repair for chronic, unstable Lisfranc injury without osteoarthritis have improved patient outcome and few post-surgical complications. While the quality of these studies is satisfactory, a larger patient cohort and prospective analysis could further strengthen arguments for or against certain surgeries. LEVEL OF EVIDENCE: Level IV; Systematic Review of Level IV Studies.

Three-dimensional correction of fibular hemimelia using a computer-assisted planning : technical report and literature review.

The purpose of this survey in Belgium and the Netherlands was to assess treatment variation in glenohumeral osteoarthritis between experienced and less experienced orthopedic surgeons, and to investigate perioperative treatment after shoulder arthroplasty in a large group of orthopedic surgeons. Orthopedic surgeons specialized in shoulder surgery were invited to complete a survey between November 2013 and February 2015. Seventy-one percent of the approached surgeons com-pleted the survey. Less experienced surgeons (< 6 years) and surgeons from the Netherlands find patient characteristics (e.g. smoking p=0.01) more relevant than more experienced surgeons (≥ 6 years) and surgeons from Belgium. Less experienced surgeons will less likely (p=0.001) perform resurfacing arthroplasty compare to experienced surgeons. The less and the experienced surgeons use similar indications for a reverse shoulder arthroplasty regarding age limit and cuff arthropathy without osteoarthritis. Less experienced surgeon will more likely (p=0.003) prescribe a low molecular weight heparin during the hospital stay after a shoulder arthroplasty. In this survey, we found a decrease in the use of resurfacing arthroplasty and a strong increase in the use of reverse shoulder arthroplasty. Besides, there is little consensus concerning pre-operative planning, patient characteristics, surgical technique, and patient reported outcome measures. Level of evidence: IV.

Improvement in sleep quality after total shoulder arthroplasty.

Objective: Poor sleep quality due to nocturnal pain is increasingly reported as a major symptom in advanced glenohumeral arthritis. The current study aimed to evaluate preoperative and postoperative sleep quality, shoulder pain, and function in patients who underwent total shoulder arthroplasty (TSA). Preoperative factors contributing to delayed improvements in sleep quality were examined.Methods: Patients scheduled for anatomic or reverse TSA due to glenohumeral arthritis were included. Patients completed the Pittsburgh Sleep Quality Index (PSQI) and American Shoulder and Elbow Surgeons (ASES) survey preoperatively, and at 6 weeks, 3 months, 6 months, and 1 year following surgery. A higher PSQI score (maximum 21) indicated greater sleep disturbance.Results: Seventy-four patients (34 males, 40 females), with a mean age of 65.8 years were prospectively enrolled. Eighty-four percent of patients reported preoperative PSQI scores indicative of sleep disturbance (6 or greater), with a mean of 10.1 ± 4.3. The PSQI score significantly improved to 7.7 at 6 weeks (P = .003), and to 6.1 at 3 months (P = .08). At 12 months, the PSQI was within normal limits (less than or equal to 5) with a mean score of 4.3. A normal PSQI score was achieved by 40.8%, at 6 weeks, 50% at 3 months, 53.7% at 6 months, and 73.9% at 1 year. The ASES score significantly improved from 32.6 ± 17.2 at baseline to 58.4 at 6 weeks (p < .001), 76.1 at 3 months (p < .001), and 85.3 at 12 months. Linear regression demonstrated that the ASES and PSQI scores were negatively associated with each other at each time point. Body mass index and female gender were associated with a delayed return to baseline sleep quality.Conclusion: Shoulder-related sleep disturbance significantly improved at 6 weeks following TSA, and normalized for most patients by 1 year post-operatively. Enhanced sleep quality after TSA was directly related to improved functional outcomes.

Is load application necessary when using computed tomography scans to diagnose syndesmotic injuries? A cadaver study.

BACKGROUND: Injuries to the distal tibio-fibular ligaments are common. While pronounced injuries can be reliably diagnosed using conventional radiographs, assessment of subtle syndesmotic injuries is challenging. This cadaver study determines the impact of loading on the assessment of incomplete and more complete syndesmotic injuries when using weightbearing computed tomography (CT) scans. METHODS: Fourteen paired male cadavers (tibial plateau to toe-tip) were included. A radiolucent frame held specimens in a plantigrade position while both non-weightbearing and weightbearing computed tomography (CT) scans were taken. The following conditions were tested: First, intact ankles (Native) were scanned. Second, one specimen from each pair underwent anterior inferior tibio-fibular ligament (AITFL) transection (Condition 1A), while the contralateral underwent deltoid transection (Condition 1B). Third, the remaining intact deltoid or AITFL was transected from each specimen (Condition 2). Finally, the distal tibiofibular interosseous membrane (IOM) was transected in all ankles (Condition 3). Eight different measurements were performed to assess the integrity of the distal tibio-fibular syndesmosis on axial CT scans. RESULTS: Load application had no impact on most measurements. While incomplete syndesmotic injuries could not be identified, cadavers with more complete injuries differentiated from native ankles when assessed using axial CT images. No significant difference was evident between discrete AITFL or deltoid ligament transection. CONCLUSIONS: In a cadaver model, load application had no effect on the assessment of the distal tibio-fibular syndesmosis in incomplete and more complete syndesmotic injuries. Only more complete injuries of the distal tibio-fibular syndesmosis could be identified using axial CT images.

Imaging in Lisfranc injury: a systematic literature review.

OBJECTIVES: To systematically review current diagnostic imaging options for assessment of the Lisfranc joint. MATERIALS AND METHODS: PubMed and ScienceDirect were systematically searched. Thirty articles were subdivided by imaging modality: conventional radiography (17 articles), ultrasonography (six articles), computed tomography (CT) (four articles), and magnetic resonance imaging (MRI) (11 articles). Some articles discussed multiple modalities. The following data were extracted: imaging modality, measurement methods, participant number, sensitivity, specificity, and measurement technique accuracy. Methodological quality was assessed by the QUADAS-2 tool. RESULTS: Conventional radiography commonly assesses Lisfranc injuries by evaluating the distance between either the first and second metatarsal base (M1-M2) or the medial cuneiform and second metatarsal base (C1-M2) and the congruence between each metatarsal base and its connecting tarsal bone. For ultrasonography, C1-M2 distance and dorsal Lisfranc ligament (DLL) length and thickness are evaluated. CT clarifies tarsometatarsal (TMT) joint alignment and occult fractures obscured on radiographs. Most MRI studies assessed Lisfranc ligament integrity. Overall, included studies show low bias for all domains except patient selection and are applicable to daily practice. CONCLUSIONS: While conventional radiography can demonstrate frank diastasis at the TMT joints; applying weightbearing can improve the viewer's capacity to detect subtle Lisfranc injury by radiography. Although ultrasonography can evaluate the DLL, its accuracy for diagnosing Lisfranc instability remains unproven. CT is more beneficial than radiography for detecting non-displaced fractures and minimal osseous subluxation. MRI is clearly the best for detecting ligament abnormalities; however, its utility for detecting subtle Lisfranc instability needs further investigation. Overall, the available studies' methodological quality was satisfactory.

Anatomy and Biomechanics of Cavovarus Deformity.

A high longitudinal plantar arch, varus position of the heel, forefoot equinus, and pronation of the first ray are characteristic of a cavovarus deformity. Forefoot-driven and hindfoot-driven deformities are distinguished based on pathomechanics. In first ray strong plantarflexion, the forefoot touches the ground first. This leads to compensatory varus heel, lock of the midfoot, reduction of the flexible phase, and decrease in shock absorption. In hindfoot-driven cavovarus deformity, the subtalar joint may compensate for varus deformities above the ankle joint. Overload of the lateral soft tissue structures and degenerative changes may occur in longstanding cavovarus deformity.

Impact of Torque on Assessment of Syndesmotic Injuries Using Weightbearing Computed Tomography Scans.

BACKGROUND: The diagnosis of subtle injuries to the distal tibiofibular syndesmosis remains elusive. Conventional radiographs miss a large subset of injuries that present without frank diastasis. This study evaluated the impact of torque application on the assessment of syndesmotic injuries when using weightbearing computed tomography (CT) scans. METHODS: Seven pairs of male cadavers (tibia plateau to toe-tip) were included. CT scans with axial load application (85 kg) and with (10 Nm) or without torque to the tibia (corresponding to external rotation of the foot and ankle) were taken during 4 test conditions. First, intact ankles (native) were scanned. Second, 1 specimen from each pair underwent anterior inferior tibiofibular ligament (AITFL) transection (condition 1A), while the contralateral underwent deltoid transection (condition 1B). Third, the lesions were reversed on the same specimens and the remaining intact deltoid or AITFL was transected (condition 2). Finally, the distal tibiofibular interosseous membrane (IOM) was transected in all ankles (condition 3). Measurements were performed to assess the integrity of the distal tibiofibular syndesmosis on digitally reconstructed radiographs (DRRs) and on axial CT scans. RESULTS: Torque impacted DRR and axial CT scan measurements in almost all conditions. The ability to diagnose syndesmotic injuries using axial CT measurements improved when torque was applied. No significant syndesmotic morphological change was observed with or without torque for either isolated AITFL or deltoid ligament transection. DISCUSSION: Torque application had a notable impact on two-dimensional (2-D) measurements used to diagnose syndesmotic injuries for both DRRs and axial CT scans. Because weightbearing conditions allow for standardized positioning of the foot while radiographs or CT scans are taken, the combination of axial load and torque application may be desirable. CLINICAL RELEVANCE: Application of torque to the tibia impacts 2-D measurements and may be useful when diagnosing syndesmotic injuries by DRRs or axial CT images.

Conversion of painful tibiotalocalcaneal arthrodesis to total ankle replacement using a 3-component mobile bearing prosthesis.

BACKGROUND: The aim of this study was to assess the short-term clinical and radiographic outcomes in patients who underwent conversion of a painful tibiotalocalcaneal arthrodesis to a total ankle replacement. METHODS: Six patients with painful ankle arthrodesis after tibiotalocalcaneal arthrodesis were included in this study. In all patients, conversion to total ankle replacement was performed using a 3rd-generation, non-constrained, cementless three-component prosthesis. The outcomes were analyzed at a mean follow-up of 3.4±1.9years (range 1.0-6.5). RESULTS: One patient with painful arthrofibrosis underwent two open arthrolysis procedures at 1.2 and 5.6 years post index surgery, respectively. No revision of tibial or talar prosthesis components was necessary in this study. All patients reported significant pain relief and significant improvement in functional status. CONCLUSION: In the present study, the conversion of a painful ankle arthrodesis following tibiotalocalcaneal arthrodesis to a total ankle replacement was a reliable surgical treatment.

Surgical outcome in chronic syndesmotic injury: A systematic literature review.

BACKGROUND: Chronic injuries of the distal tibio-fibular syndesmosis often present with non-specific clinical and radiographic findings. If chronic instability to the distal tibio-fibular syndesmosis is verified, various reconstruction options are available. The purpose of this article is to give a systematic review of current surgical treatment options in patients with chronic syndesmotic injury. METHODS: Three major medical databases were searched from inception through December 12, 2017: PubMed, ScienceDirect, and SpringerLink. Studies were included if they were original research studies which assessed the outcome of patients treated surgically for chronic syndesmotic instability. Only studies written in English were considered. The following data were extracted from each study: number of patients and ankles included, average patients' age, gender, study design, preoperative examination, time between the initial injury and the operation, postoperative follow-up time, operative technique, complication rates, and clinical outcome. The modified Coleman Score was used to assess the methodologic quality of the included studies. RESULTS: Seventeen (17) studies were included. All studies were retrospective or prospective case series. Each study was performed at a single center. In general, good functional outcomes and low complication rates were reported. The American Orthopaedic Foot and Ankle (AOFAS) score was most frequently used outcome tool to measure postoperative outcomes. The quality of the included studies was overall satisfactory. CONCLUSIONS: A few studies have reported on the operative outcomes after treating chronic syndesmotic instability. Several different techniques were used to treat this problem. The quality of current studies is overall satisfactory but could be improved with larger patient numbers and prospective analysis. Recognition of this clinical entity as an identifiable and treatable cause of ankle pain requires vigilant clinical investigation. LEVEL OF EVIDENCE: Level IV; Systematic Review of Level IV Studies.