Arthroscopic Talar Dome Access Using a Standard Versus Wire-Based Traction Method for Ankle Joint Distraction.

PURPOSE: To evaluate the accessibility of the talar dome through anterior and posterior portals for ankle arthroscopy with the standard noninvasive distraction versus wire-based longitudinal distraction using a tensioned wire placed transversely through the calcaneal tuberosity. METHODS: Seven matched pairs of thigh-to-foot specimens underwent ankle arthroscopy with 1 of 2 methods of distraction: a standard noninvasive strapping technique or a calcaneal tuberosity wire-based technique. The order of the arthroscopic approach and use of a distraction method was randomly determined. The areas accessed from both 2-portal anterior and 2-portal posterior approaches were determined by using a molded translucent grid. RESULTS: The mean talar surface accessible by anterior ankle arthroscopy was comparable with noninvasive versus calcaneal wire distraction with 57.8% ± 17.2% (range, 32.9% to 75.7%) versus 61.5% ± 15.2% (range, 38.5% to 79.1%) of the talar dome, respectively (P = .590). The use of calcaneal wire distraction significantly improved posterior talar dome accessibility compared with noninvasive distraction, with 56.4% ± 20.0% (range, 14.4% to 78.0%) versus 39.8% ± 14.9% (range, 20.0% to 57.6%) of the talar dome, respectively (P = .031). CONCLUSIONS: Under the conditions studied, our cadaveric model showed equivalent talar dome access with 2-portal anterior arthroscopy of calcaneal wire-based distraction versus noninvasive strap distraction, but improved access for 2-portal posterior arthroscopy with calcaneal wire-based distraction versus noninvasive strap distraction. CLINICAL RELEVANCE: The posterior 40% of the talar dome is difficult to access via anterior ankle arthroscopy. Posterior calcaneal tuberosity wire-based longitudinal distraction improved arthroscopic access to the centro-posterior talar dome with a posterior arthroscopic approach.

Readability and quality of online information on total ankle arthroplasty.

The internet is a frequently utilized resource to acquire health information. This study aims to examine the readability and quality of online information pertaining to total ankle arthroplasty (TAA). "Ankle arthroplasty" OR "ankle replacement" was queried in three search engines, with the first 3 pages of results identified. The readability of sites was calculated using six readability algorithms: Flesch-Kincaid grade level, Flesch Reading Ease, Gunning Fog, SMOG, Coleman-Liau index, and Automated Readability Index. Quality was assessed using the JAMA benchmark, Global Quality Score (GQS), and DISCERN instrument. A total of 62 relevant sites were analyzed. Sources were primarily physician-sponsored (50%) or academic (31%) websites. The mean readability indices were above the recommended sixth grade reading level, with an average grade level of across scoring tools of 13.22 ± 2.07. No sites were at or below a sixth grade reading level. Quality ratings were subpar across assessment tools: JAMA = 1.9 ± 1.0 (range, 1-4) out of 4; GQS = 3.4 ± 1.0 (range, 1-5) out of 5. DISCERN = 54.0 ± 11.2 (range, 31-75) out of 80. The readability and quality of online information regarding ankle arthroplasty is not optimal for the average patient, with improvement valuable in cultivating shared decision-making.

YouTube as a Source of Patient Information for Ankle Arthroplasty: Quantitative Analysis of Video Reliability, Quality, and Content.

Background. There are limited data on the quality and content of videos discussing total ankle arthroplasty (TAA) on the YouTube video platform. Methods. The first 60 unique YouTube videos resulting from the keyword query "ankle arthroplasty" and "ankle replacement" were analyzed for comprehensiveness and quality. Content was assessed using the Journal of American Medical Association (JAMA) benchmark criteria, DISCERN, Global Quality Scale (GQS), and an arthroplasty-specific score. Results. Videos demonstrated low mean DISCERN (49.2/80), GQS (3.2/5), and arthroplasty-specific scores (4.3/12) with substantial variability between videos. Most of the content was produced by nonacademic physicians (46.7%) and academic sources (21.7%). Academic videos saw significantly higher mean JAMA scores (P = .013) but were otherwise comparable to non-academic physicians. Commercial content demonstrated significantly low-quality scores compared to academic (P = .012) and physician (P = .008) sources despite the highest mean viewership. Conclusions. Information on TAA on the YouTube platform is highly variable based on video source, with generally poor quality and content.Level of Evidence: Level V, systemic review of non-peer reviewed resources.

Traumatic Fibular Loss Managed with a Free Vascularized Fibular Graft: A Case Report.

CASE: A 25-year-old man involved in a jet skiing accident experienced a traumatic excision of his distal fibula in conjunction with other lower extremity injuries. He subsequently underwent a reconstruction of his lateral malleolus using an ipsilateral free vascularized fibular graft (FVFG) from his proximal fibular shaft, resulting in a preserved and stabilized ankle joint at 1 year. CONCLUSION: Traumatic distal fibular excision is a rare injury that can be successfully managed using an FVFG, with fusion of the distal syndesmosis and a symmetric ankle mortise observed at the 1-year follow-up.

Readability of Online Foot and Ankle Surgery Patient Education Materials.

Background. Online health education resources are frequently accessed by patients seeking information on orthopaedic conditions and procedures. The objectives of this study were to assess the readability of information provided by the American Orthopaedic Foot and Ankle Society (AOFAS) and compare current levels of readability with previous online material. Methods. This study examined 115 articles classified as "Conditions" or "Treatments" on FootCareMD.org. Readability was assessed using the 6 readability assessment tools: Flesch Reading Ease, Flesch-Kincaid Grade Level (FKGL), Gunning Fog Score, Simple Measure of Gobbledygook (SMOG) Index, Coleman-Liau Index, and the Automated Readability Index. Results. The mean readability score across all metrics ranged from 9.1 to 12.1, corresponding to a 9th- to 12th-grade reading level, with a mean FKGL of 9.2 ± SD 1.1 (range: 6.3-15.0). No articles were written below the recommended US sixth-grade reading level, with only 3 articles at or below an eighth-grade level. Treatment articles had higher mean readability grade levels than condition articles (P = .03). Conclusion. Although the volume and quality of the AOFAS resource Web site has increased, readability of information has worsened since 2008 and remains higher than the recommended reading level for optimal comprehension by the general population.Levels of Evidence: Level IV:Retrospective quantitative analysis.

High-Volume and Privately Owned Ambulatory Surgical Centers Reduce Costs in Achilles Tendon Repair.

BACKGROUND: While Achilles tendon repairs are common, little data exist characterizing the cost drivers of this surgery. PURPOSE: To examine cases of primary Achilles tendon repair, primary repair with graft, and secondary repair to find patient characteristics and surgical variables that significantly drive costs. STUDY DESIGN: Economic and decision analysis; Level of evidence, 3. METHODS: A total of 5955 repairs from 6 states were pulled from the 2014 State Ambulatory Surgery and Services Database under the Current Procedural Terminology codes 27650, 27652, and 27654. Cases were analyzed under univariate analysis to select the key variables driving cost. Variables deemed close to significance (P < .10) were then examined under generalized linear models (GLMs) and evaluated for statistical significance (P < .05). RESULTS: The average cost was $14,951 for primary repair, $23,861 for primary repair with graft, and $20,115 for secondary repair (P < .001). In the GLMs, high-volume ambulatory surgical centers (ASCs) showed a cost savings of $16,987 and $2854 in both the primary with graft and secondary repair groups, respectively (both P < .001). However, for primary repairs, high-volume ASCs had $2264 more in costs than low-volume ASCs (P < .001). In addition, privately owned ASCs showed cost savings compared with hospital-owned ASCs for both primary Achilles repair ($2450; P < .001) and primary repair with graft ($11,072; P = .019). Time in the operating room was also a significant cost, with each minute adding $36 of cost in primary repair and $31 in secondary repair (both P < .001). CONCLUSION: Private ASCs are associated with lower costs for patients undergoing primary Achilles repair, both with and without a graft. Patients undergoing the more complex secondary and primary with graft Achilles repairs had lower costs in facilities with greater caseload.

Surgical Considerations for Osteoporosis in Ankle Fracture Fixation.

As the geriatric population and associated ankle fractures continues to increase, fracture surgeons should be prepared to surgically manage osteoporotic ankle fractures. There are abundant challenges in management, soft tissue care, and fixation of ankle fractures with poor bone quality especially in elderly patients who have difficulty limiting weight bearing. This article summarizes several different surgical techniques that can be used to optimize outcomes of these fractures.

Variability in Foot and Ankle Case Volume in Orthopaedic Residency Training.

Surgical case volume during orthopaedic surgical residency is a concern among trainees and program directors alike. With an ongoing trend toward further subspecialization and the rapid development of new techniques and devices, the breadth of procedures that residents are exposed to continues to increase. Accreditation Council for Graduate Medical Education surgical case logs from 2009 to 2013 for graduating orthopaedic surgery residents were examined to assess the national averages of orthopaedic procedures logged by graduating orthopaedic surgery residents in the leg/ankle and foot/toes categories. This investigation revealed that there was an 8% increase in the total number of leg/ankle cases and 12% increase in foot/toes cases performed by graduating orthopaedic surgery residents, which has not significantly increased from 2009 to 2013. Across years examined in this study, significant variability existed between the 10th and 90th percentiles for total foot and ankle resident case exposure (P < .05), particularly within ankle arthroscopy, where there was a 15-fold difference in the number of arthroscopy cases performed by residents in the 90th percentile compared with the 10th percentile. The overall volume of foot and ankle cases performed by graduating orthopaedic surgery residents has increased despite not being statistically significantly from 2009 to 2013. LEVELS OF EVIDENCE: Level III: Cohort study.

Use of a Pneumatic Limb Positioner for Invasive Skeletal Traction in Posterior Hindfoot Arthroscopy.

Posterior hindfoot arthroscopy is a useful tool to treat a variety of foot and ankle pathologies. Skeletal distraction of the hindfoot to increase visualization in posterior ankle arthroscopy has been described in previous studies, but the described distractor is not readily available in most operating rooms. We describe a case of posterior hindfoot distraction in the prone position using a pneumatic limb positioner and other readily available Food and Drug Administration-approved equipment to apply tension to a transcalcaneal wire. The distraction technique we describe does not require any custom equipment, can fit on most standard operating tables, and is readily available in standard operating rooms. This method achieves adequate distraction, resulting in better visualization and more space for arthroscopic instrumentation.

Evaluation of saline load test for simulated traumatic arthrotomies of the ankle.

INTRODUCTION: A tool frequently used for evaluation of a traumatic arthrotomy is the saline load test. No information exists in the current literature guiding what baseline fluid infusion is required to reliably detect or diagnose a traumatic ankle arthrotomy. The purpose of this study was to provide a reliable benchmark when employing the saline load test for complex ankle soft-tissue wounds with suspected intra-articular involvement. MATERIALS AND METHODS: Twenty-one consecutive patients presenting for elective ankle arthroscopy underwent simulated saline load tests. After placement of an approximately 4-mm standard lateral portal, an 18-gauge needle was inserted into the anteromedial ankle joint and normal saline was injected until frank extravasation from the lateral arthrotomy was observed. The amount of saline required to diagnose a simulated traumatic arthrotomy was recorded. RESULTS: The average amount of normal saline that resulted in extravasation was 10.3 cm(3). In order to identify 90% and 95% of simulated ankle arthrotomies, 23 and 30 cm(3) of saline were required, respectively. The average preoperative range of motion did not correlate with saline infusion requirements (r(2)=0.013368). CONCLUSIONS: Based on these results, a minimum infusion of 30 cm(3) is recommended to identify 95% of traumatic arthrotomies approximately 4mm in size. This value needs to be interpreted with the understanding that this study is limited by its inherently simulated nature. An infusion of 30 cm(3) represents a relatively safe and reasonable standard to apply to any potential ankle injury in which joint violation remains in question.

Biomechanical evaluation of mini-fragment hardware for supination external rotation fractures of the distal fibula.

BACKGROUND: Supination external rotation distal fibula fractures are common, requiring fixation when associated with talar displacement. Subcutaneous distal fibula hardware may become painful, necessitating operative removal. We hypothesize that mini-fragment and small-fragment constructs will demonstrate similar biomechanical stability. METHODS: A biomechanical comparison was performed in synthetic osteoporotic sawbones. The first arm compared two 2.4-mm lag screws with one 3.5-mm lag screw for fixation of a simulated supination external rotation distal fibula fracture. The second arm compared a 2.4-mm plate-screw construct with a 3.5-mm lag screw and one-third tubular neutralization plate. During torsional testing, torque and displacement were recorded, and stiffness and peak torque were determined. RESULTS: Differences in mean stiffness and mean load at failure were not statistically significant with lag screw-only fixation. The 3.5-mm plate-screw construct outperformed the 2.4-mm plate-screw construct, but neither mean stiffness nor mean load at failure were statistically significantly different. Dynamic testing also demonstrated similar results. CONCLUSION: Our data suggest that isolated 2.4-mm screws function similarly to one 3.5-mm screw. Although the 3.5-mm plate-screw construct was stiffer, mean load at failure was equivalent for the 2 constructs. These data provide biomechanical evidence to support further investigation in the use of mini-fragment hardware for distal fibula fracture fixation. LEVELS OF EVIDENCE: Therapeutic, Level V.

What is the role and limit of calcaneal osteotomy in the cavovarus foot?

Calcaneal osteotomy is a commonly used tool in cavovarus foot reconstructions. Understanding the indications and limitations of such an osteotomy is critical to success in reconstruction. We present a comprehensive review of surgical calcaneal osteotomy techniques and the currently available state of literature for their indications and limitations.

Correction of metatarsus primus varus associated with hallux valgus deformity using the arthrex mini tightrope: a report of 44 cases.

Metatarsus primus varus must be addressed during correction of moderate to severe hallux valgus deformity. As an alternative to proximal osteotomy or first tarsometatarsal fusion for hallux valgus correction, this study presents a series of patients treated using the Arthrex Mini TightRope. A total of 36 patients (44 operations) with hallux valgus and metatarsus primus varus underwent correction using the Arthrex Mini TightRope. Assessment included measurement of radiographic parameters, the American Orthopaedic Foot and Ankle Society (AOFAS) midfoot outcomes score, and the SF-12. The average hallux valgus angle improved from 32.2° to 15.2° (P < .0001). The average first intermetatarsal angle improved from 14.6° to 8.2° (P < .0001). The average distal metatarsal articular angle improved from 17.0° to 9.6° (P < .0001). The average AOFAS midfoot outcomes scores improved from 45.44 to 84.72 (P < .0001). Postoperative SF-12 physical and mental scores averaged 52.99 and 56.63. Only one patient had recurrence of deformity. Correcting metatarsus primus varus in association with hallux valgus deformity using the Arthrex Mini TightRope should be considered a treatment option. This technique is less invasive and seems capable of maintaining correction while allowing for early weight bearing and avoiding the need for a proximal first metatarsal osteotomy or Lapidus procedure.

Carpal kinematics after proximal row carpectomy.

PURPOSE: Proximal row carpectomy (PRC) is a clinically useful motion-sparing procedure for the treatment of certain degenerative conditions of the wrist. Clinical outcome studies after PRC have shown that wrist flexion-extension averages approximately 60% of that of the contralateral wrist. The purpose of this study was to determine how the kinematics of the wrist are altered after PRC. METHODS: Eight fresh-frozen cadaver forearms were scanned with computed tomography before and after PRC. Forearms were scanned in 5 different wrist positions (neutral, extension, flexion, radial deviations, and ulnar deviation). Wrists were positioned dynamically and then held statically in a custom fixture through forces applied to the 4 wrist flexor/extensor tendon groups. Three-dimensional computer models of the radius, lunate, and capitate were generated from the computed tomographic images, and the kinematics of the capitate and lunate were calculated relative to the neutral position. For the intact wrist, the motion of the capitate was calculated relative to both the lunate (midcarpal motion) and the radius (overall wrist motion) and the motion of the lunate was calculated relative to the radius (radiocarpal motion). After PRC, only the movement of the capitate relative to the radius was calculated, which represents radiocapitate and overall wrist motion. All motions were plotted in 3 dimensions for purposes of qualitative visualization. RESULTS: After PRC, the capitate articulated with the lunate fossa of the radius for all positions in all samples. Overall wrist motion decreased 28%, 30%, 40%, and 12% in flexion, extension, radial deviation, and ulnar deviation, respectively. Motion at the radiocarpal joint after PRC, however, was greater compared with motion at the radiocarpal and midcarpal joints of the intact wrist during flexion and extension. This was not the case in radial deviation because of impingement of the trapezoid on the radial styloid. In radial and ulnar deviation, motion of the capitate head changed from predominantly rotational in the intact wrist (midcarpal joint) to a combination of rotation and translation after PRC (radiocarpal joint). CONCLUSIONS: Removal of the proximal carpal row decreased normal wrist flexion and extension. Although ulnar deviation was preserved, radial deviation was limited by impingement of the trapezoid on the radial styloid. Radiocapitate range of motion after PRC was greater than capitolunate range of motion in the intact wrists. Compared with previously published requirements, wrist range of motion observed after PRC was sufficient for activities of daily living.

Kinematics of the midcarpal and radiocarpal joint in flexion and extension: an in vitro study.

PURPOSE: To apply carpal kinematic analysis using noninvasive medical imaging to investigate the midcarpal and radiocarpal contributions to wrist flexion and extension in a quasidynamic in vitro model. METHODS: Eight fresh-frozen cadaver wrists were scanned with computed tomography in neutral, full flexion, and full extension. Body-mass-based local coordinate systems were used to track motion of the capitate, lunate, and scaphoid with the radius as a fixed reference. Helical axis motion parameters and Euler angles were calculated for flexion and extension. RESULTS: Minimal out-of-plane carpal motion was noted with the exception of small amounts of ulnar deviation and supination in flexion. Overall wrist flexion was 68 degrees +/- 12 degrees and extension was 50 degrees +/- 12 degrees. In flexion, 75% of wrist motion occurred at the radioscaphoid joint, and 50% occurred at the radiolunate joint. In extension, 92% of wrist motion occurred at the radioscaphoid joint, and 52% occurred at the radiolunate joint. Midcarpal flexion/extension between the capitate and scaphoid was 0 degrees +/- 5 degrees in extension and 10 degrees +/- 13 degrees in flexion. Midcarpal flexion/extension between the capitate and lunate was larger, with 15 degrees +/- 11 degrees in extension and 22 degrees +/- 19 degrees in flexion. CONCLUSIONS: The capitate and scaphoid tend to move together. This results in greater flexion/extension for the scaphoid than the lunate at the radiocarpal joint. The lunate has greater midcarpal motion between it and the capitate than the scaphoid does with the capitate. The engagement between the scaphoid and capitate is particularly evident during wrist extension. Out-of-plane motion was primarily ulnar deviation at the radiocarpal joint during flexion. These results are clinically useful in understanding the consequences of isolated fusions in the treatment of wrist instability.