What Is the Risk of Irrigation and Debridement Following Foot and Ankle Surgery? Development of a Risk Severity Scoring System.

BACKGROUND: Surgical site infection (SSI) after foot and ankle surgery has serious negative effects on patient health and quality of life. While previous studies have looked at predisposing factors for SSI, to our knowledge, no study has proposed a risk severity score. QUESTIONS/PURPOSES: Can a risk severity score, based on patient demographic characteristics and surgical variables, be developed for preoperative use in patients undergoing foot and ankle surgery that will calculate the risk of an irrigation and debridement (I&D) procedure within 90 days of surgery utilizing data from previous surgeries? METHODS: A retrospective chart study was performed on patients undergoing foot and ankle surgery. Data on demographic characteristics including age, sex, and BMI were recorded. Data on patient factors including diabetes and smoking history were also recorded. Surgical details including length of surgery, procedure type, surgeon, antibiotic delivery time, antibiotic type, and antibiotic dose were analyzed. Of 2979 procedures, 1% (36) of I&Ds were performed within 90 days. The mean age at surgery was 49 ± 17 years, and 57% (1702) of patients were female. The mean BMI was 28 ± 6 kg/m2. The primary outcome was I&D within 90 days postoperatively. Descriptive statistics of differences in patient characteristics between those who underwent I&D and those who did not were examined using chi-square tests and t-tests (p < 0.05 was taken as significant). Significant variables from a simple regression analysis were included in a multiple logistic regression model with a forward stepwise procedure for variable selection. We required all data in the model to be categorical; thus, continuous variables such as time were dichotomized. We factored odds ratios determined by multiple regression for significant variables into the final risk severity score, and an easy-to-use tool based on this risk severity score was created in Excel (Microsoft). RESULTS: Current tobacco use, diabetes, and longer operative times were the only factors associated with I&D within 90 days postoperatively. A risk severity score was developed using current tobacco use, diabetes, and length of surgery greater than 60 minutes as factors. A patient with a severity score of 0 (no risk factors) had a 0.6% chance of I&D within 90 days, while a severity score of 1 indicated a 1.1% chance, a score of 2 indicated a 2.1% chance, a score of 3 indicated a 4.0% chance, and a score of 4 (all risk factors) indicated a 7.5% chance of I&D within 90 days. A spreadsheet that can be used at the point of care was created based on these findings. CONCLUSION: Our risk severity score may help inform preoperative patient guidance and operative planning. Calculating the score in the office setting during preoperative visits can also improve communication between physician and patient. Future research should focus on validation of this risk severity score at multiple institutions. LEVEL OF EVIDENCE: Level III, prognostic study.

TENDINopathy Severity assessment-Achilles (TENDINS-A): evaluation of reliability and validity in accordance with COSMIN recommendations.

OBJECTIVE: To evaluate the construct validity (structural validity and hypothesis testing), reliability (test-retest reliability, measurement error and internal consistency) and minimal important change (MIC) of the 13-item TENDINopathy Severity assessment-Achilles (TENDINS-A). METHODS: Participants with Achilles pain completed an online survey including: demographics, TENDINS-A, Foot and Ankle Outcome Score (FAOS) and Victorian Institute of Sport Assessment-Achilles (VISA-A). Exploratory factor analysis (EFA) assessed dimensionality. Confirmatory factor analysis (CFA) assessed structural validity (root mean square error of approximation (RMSEA); Comparative Fit Index (CFI); Tucker-Lewis Index (TLI); standardised root measure square (SRMS)). Correlations between TENDINS-A and the FAOS or VISA-A assessed hypothesis testing. Intraclass correlation (ICC) assessed test-retest reliability. Cronbach's alpha assessed internal consistency. SE of the measurement (SEM) assessed measurement error. A distribution-based approach assessed MIC. RESULTS: 79 participants (51% female) with a mean (SD) age=42.6 (13.0) years, height=175.0 (11.7) cm and body mass=82.0 (19.1) kg were included. EFA identified three meaningful factors, proposed as pain, symptoms and function. The best model identified using CFA for TENDINS-A had structural validity (RMSEA=0.101, CFI=0.959, TLI=0.947, SRMS=0.068), which included three factors (pain, symptoms and function), but excluded three items from the original TENDINS-A. TENDINS-A exhibited moderate positive correlation with FAOS (r=0.598, p<0.001) and a moderate negative correlation with VISA-A (r=-0.639, p<0.001). Reliability of the TENDINS-A was excellent (ICC=0.930; Cronbach's α=0.808; SEM=6.54 units), with an MIC of 12 units. CONCLUSIONS: Our evaluation of the revised 10-item TENDINS-A determined it has construct validity and excellent reliability, compared with the VISA-A and FAOS which lack content and construct validity. The TENDINS-A is recommended as the preferred patient-reported outcome measure to assess disability in people with Achilles tendinopathy.

Surgical Treatment of the Flexible, Progressive Collapsing Foot: Deformities, Definitions, and Decisions.

The complex adult acquired flatfoot deformity involves progressive collapse of the foot with attenuation of medial soft tissues such as the posterior tibialis tendon and spring ligament complex. Multiple deformities at different levels can coexist in the collapsed foot, including hindfoot valgus, midfoot abduction, forefoot varus, and valgus ankle instability. Definitions of flatfoot have evolved to encapsulate the peritalar basis of the deformity, with instability around the talus as the fulcrum. The goals of treatment are to minimize pain, dysfunction, and progressive deformity. Some treatment options directly address the pathologic areas, such as tendon transfer for posterior tibialis tendon dysfunction and spring ligament reconstruction. Others such as calcaneal osteotomies secondarily counteract the primary ligamentous dysfunction and realign the foot to neutralize deforming forces. Selective fusions of the hindfoot and medial column are also viable options to correct the deformity at the joint level when appropriate. The treatment selected depends on flexibility and locations of the deformity, and ultimately patient-specific factors.

Combining radiographic and CT measurements to rival MRI for the diagnosis of acute isolated syndesmotic injury.

BACKGROUND: Acute isolated syndesmotic injuries (AISIs) have a high potential to be misdiagnosed or underdiagnosed at initial presentation to the hospital. Although magnetic resonance imaging (MRI) is the gold standard in noninvasive diagnostics, it is not always available immediately and is much more expensive than other imaging modalities. This study identifies improvements in conventional radiography and computed tomography (CT) to diagnose AISI and aims to reduce the number of MRI scans needed to verify the diagnosis. METHODS: A retrospective case match control study was conducted by searching our trauma database between 2008 and 2022. A study group of patients with AISI (n = 64) and a control group of patients without AISI (n = 76) were formed to generate an equal number of images from both groups (62 radiographs and 22 CT scans). A total of 16 parameters that quantify the distal tibiofibular relation in injured and uninjured ankles were analyzed. For statistical analysis, a two-sided t-test was applied to calculate significant differences (p < 0.05). In a further step, a receiver operating characteristic curve (ROC) was used to determine cut-off values for the most significant parameters. RESULTS: The most significant measurement (p < 0.001) on axial CT scans was the syndesmotic area (SA). The ROC curve revealed an area under the curve (AUC) of 0.94 (95% CI 0.86-1.0) and a cut-off value of 71.68 mm2 that shows a sensitivity and specificity of 95.5% and 81.8%, respectively. CONCLUSION: This study suggests that radiographic imaging could represent an equally accurate alternative to MRI. These methods might generate the correct diagnosis faster due to their availability and inexpensiveness. By applying our new cut-off values in a clinical setting, the number of underdiagnosed and untreated unstable syndesmotic injuries could be reduced. LEVEL OF EVIDENCE: III, retrospective comparative study.

Revision Surgery and Wound Complications with Minimally Invasive Compared to Open Achilles Tendon Repair: A Retrospective Comparative Study of 116 Patients.

The current study analyzed revision surgery rate and wound complications of patients with Achilles tendon ruptures that received either minimally invasive repair or open standard repair. A retrospective chart review of patients that had Achilles tendon repair performed using either an open or minimally invasive technique was conducted. Primary outcomes were revision surgery rate and wound complication rate. Twenty-nine (25.0%) patients had the minimally invasive approach, while 87 (75.0%) had the open approach. On average there were 0.16 additional surgeries per patient in the open group versus none in the minimally invasive group (p = 0.003). There were 13 wound-related complications, all of which were in the open group (p = 0.06). Revision surgery rates are significantly higher for patients treated with open Achilles repair versus those treated with a minimally invasive technique. Patients may benefit from a minimally invasive as opposed to open technique. (Journal of Surgical Orthopaedic Advances 32(3):173-176, 2023).

A systematic review of the patient reported outcome measures utilized in level 1 randomized controlled trials involving achilles tendon ruptures.

BACKGROUND: Patient Reported Outcome Measures (PROMs) are utilized in level 1 randomized controlled trials involving Achilles tendon ruptures. However, the characteristics of these PROMs and current practices has not yet been reported. We hypothesize that there will be heterogeneous PROM usage in this context. METHODS: A PubMed and Embase systematic review was performed including all dates up to July 27th, 2022, assessing Achilles tendon ruptures in level 1 studies using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines where applicable. Inclusion criteria were all randomized controlled clinical studies involving Achilles tendon injuries. Studies that: (1) were not level 1 evidence (including editorial, commentary, review, or technique articles), (2) omitted outcome data or PROMs, (3) included injuries aside from Achilles tendon ruptures, (4) involved non-human or cadaveric subjects, (5) were not written in English, and (6) were duplicates were excluded. Demographics and outcome measures were assessed in the studies included for final review. RESULTS: Out of 18,980 initial results, 46 studies were included for final review. The average number of patients per study was 65.5. Mean follow up was 25 months. The most common study design involved comparing two different rehabilitation interventions (48 %). Twenty different outcome measures were reported including the Achilles tendon rupture score (ATRS) (48 %), followed by the American Orthopedic Foot and Ankle score Ankle-Hindfoot score (AOFAS-AH) (46 %), the Leppilahti score (20 %), and the RAND-36/Short Form (SF) - 36/SF-12 scores (20 %). An average of 1.4 measures were reported per study. CONCLUSION: Significant heterogeneity exists in PROM usage among level 1 studies involving Achilles tendon ruptures, which prevents meaningful interpretation of these data across multiple studies. We advocate for usage of at least the disease-specific Achilles Tendon Rupture score and a global, quality of life (QOL) survey such as the SF-36/12/RAND-36. Future literature should provide more evidence-based guidelines for PROM usage in this context. LEVEL OF EVIDENCE: Level IV; Systematic Review.

Rotational abnormalities in dysplastic hips and how to predict acetabular torsion.

OBJECTIVES: The aim of this study was to investigate the degree to which conventional radiography can represent the acetabular and femoral rotational alignment profile between dysplastic and borderline-dysplastic hips. METHODS: A retrospective trial was conducted including 56 borderline-dysplastic and dysplastic hips at a mean age of 28.9 years (range from 18 to 46). Inclusion criteria consisted of symptomatic patients with hip dysplasia undergoing 2-dimensional radiography as well as computed tomography. On radiography, the lateral center edge angle, acetabular hip index, hip lateralization index, acetabular index angle, and the Sharp angle were measured, and the presence of a crossover sign was noted. In computed tomography, the full rotational profile of the lower limb was measured. RESULTS: Significant correlations were observed in the overall analysis between the anteversion of the acetabulum and the hip lateralization index (mean 0.56, coefficient of regression (CoR) -32.35, p = 0.011) as well as the acetabular index angle with a mean of 11.50 (CoR 0.544, p = 0.018). Similar results were found in the subgroup of dysplastic hips with an acetabular index angle of 13.9 (p = 0.013, CoR 0.74). For the borderline-dysplastic group, no significant correlations between the pelvis radiography and rotational CT were seen. CONCLUSION: Although the femoral and acetabular torsion cannot be predicted from x-rays, the anteversion of the acetabulum correlates with the acetabular index angle, the hip lateralization index, and eventually the beta angle in dysplastic hips. For borderline-dysplastic hips, such results did not show up, which strongly illustrates the need for computed tomography in these cases. KEY POINTS: • Much of the current literature focuses on rotational alignment especially with respect to the femur and tibia in healthy patients, although little is known about the acetabular, femoral, and tibial torsion in dysplastic hips. • This is the first study showing significant correlations between the anteversion of the acetabulum and the hip lateralization index as well as the acetabular inclination angle. Also, it is the first study to provide a mechanism for estimation of the torsion of the acetabulum with plain radiography in dysplastic hips. • In borderline-dysplastic hips, no significant correlation was found, which raises the question if a simple x-ray has enough validity to address the acetabular deformity with surgery.

Economic Impact of Unused Surgical Instruments in an Orthopaedic Surgery Department at an Academic Medical Center: A Prospective Cross-sectional Study.

Orthopaedic surgical trays contain unused instruments, but we do not know which specific instruments go unused nor do we know the savings from eliminating them from a given tray. This was a single-site, observational study conducted at an academic medical center. The primary outcome was type of unused instruments and percentage of instruments used in two commonly used surgical trays. The secondary outcome was cost savings in United States dollars (USD) that could be attained by eliminating these instruments. In the first tray, five instruments (10.6%) were unused in any of 37 observed cases. In the second tray, nineteen instruments (19.6%) were unused in 37 observed cases. The total annual savings from replacement cost analysis and reprocessing cost analysis was $6,597.00 USD. Unused instruments are common in surgical trays. Eliminating unused instruments can result in immediate cost savings. (Journal of Surgical Orthopaedic Advances 30(3):131-135, 2021).

Antegrade Screw Fixation of Medial Malleolus Fractures: A Technique Tip.

Ankle fractures are one of the most common orthopedic injuries and often include medial malleolus fractures. A number of techniques to repair medial malleolus fractures have been described. Depending on the exact fracture pattern, there are cases of medial malleolus fractures that are less amenable to standard fixation strategies. We present an alternative strategy for fixing medial malleolus fractures, in which a screw is placed antegrade across the fracture line. (Journal of Surgical Orthopaedic Advances 29(1):5052, 2020).

Isolated fibular stress fractures: Radiographic parameters.

BACKGROUND: Fibular stress fractures are uncommon injuries with an incompletely understood pathogenesis and predisposing characteristics. This study investigated the demographic and radiographic risk factors for fibular stress fractures. METHODS: A retrospective chart review from 2010 to 2018 revealed thirteen patients with isolated fibular stress fractures. Demographics, history of fracture, fracture location, bone quality, and heel alignment were collected. RESULTS: The cohort consisted of six men and seven women with a mean age of 41.8 years. The average BMI was 28.5kg/m2. Three patients used tobacco. 69.2% of fractures were in the distal third, 23.1% proximal third, and 7.7% middle third. No patients had evidence of osteopenia. Distal fibula stress fractures were more common in women (66.7%) and associated with hindfoot valgus. CONCLUSION: Distal third fibula stress fractures were most common and associated with hindfoot valgus. This could be due to a greater amount of axial force through fibula in this alignment. LEVEL OF EVIDENCE: Level IV, Retrospective Case Series.

Spinal injuries in airborne accidents: a demographic overview of 148 patients in a level-1 trauma center.

PURPOSE: The purpose of this study was to investigate the type and severity of spinal injury in airborne sports, as well as patients demographics in this unique set of athletes. Paragliding is one of the most popular airborne sports in Switzerland, which thought to be no less dangerous with a high potential for spinal injury. Few studies on spinal column injuries have been performed in these high-risk athletes with only inconsistent findings. METHODS: Patient charts were analyzed for all airborne sports injuries affecting the spine from 2010 to 2017 at a level-1 trauma center in Switzerland. To classify the injuries, we used the newest AOSpine classification, ASIA-grading and the injury severity score (ISS). In total, 235 patients were admitted to the emergency department due to an airborne injury. A total of 148 patients (148/235, 63.0%) which were predominantly male (125/235, 84.5%) at a mean age of 39.4 years suffered 334 spinal fractures and 5 spinal contusions. The mean ISS was 17.3, and the L1 vertebra was most commonly affected (47.6% of cases, 68/148). RESULTS: A total of 78 patients (54.5% or 78/148) required spine surgery due to instability or neurological deficits (31/148 patients; 20.9%). Concomitant injuries were identified in 64.2% of cases (n = 95). CONCLUSION: Due to the increasing popularity of airborne sports, age of patients and severity of injuries (ISS) increased compared with the literature. The thoracolumbal spine is at especially high risk. To prevent further complications, the treatment procedure has to be sought carefully and algorithm should be introduced in clinics to avoid delay in diagnostics and surgery. LEVEL OF EVIDENCE: III, retrospective comparative study. These slides can be retrieved under Electronic Supplementary Material.

Musculoskeletal Health Literacy, Pain Catastrophization, and Sleep Quality: Effect on Functional Disability Scores.

Limited musculoskeletal health literacy, catastrophic pain thinking, and poor sleep quality may be associated with adverse long-term health outcomes, but are sparsely studied concomitantly in orthopedics. The purpose of this study was to assess how these factors influence baseline functional disability. Hand and wrist and foot and ankle patients presenting with a previously untreated complaint were enrolled and completed the Literacy in Musculoskeletal Problems questionnaire, Pain Catastrophization Scale (PCS), and Pittsburgh Sleep Quality Index (PSQI). Upper extremity patients completed the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and lower extremity patients completed the Foot and Ankle Outcome Score (FAOS) survey. DASH and FAOS scores were normalized to the same scale and termed "functional survey" (FS). Two hundred thirty-one patients (mean age 45.8 ± 16.8) were included in the analysis. PCS and PSQI were significantly correlated with FS score. The only other variables significantly correlated with FS score were insurance and diagnosis type. The variables PCS, PSQI, insurance, and diagnosis were entered into a multivariate analysis with FS score. All four variables significantly added to FS score in the model (R2 = .194, p < .001). Interventions that target both catastrophizing tendencies and sleep quality may independently improve functional outcomes. Further in-depth multifactorial research in this topic is critical to craft effective treatments with sustainable outcomes. (Journal of Surgical Orthopaedic Advances 28(2):144-149, 2019).

Anatomy of the ankle capsule: A cadaveric study.

Although bony and ligamentous injuries of the ankle are well understood, little is known about the degree to which injury of the ankle capsule can be a component of such injuries. The purpose of this study was to determine the dimensions of the ankle capsule and its relationship to adjacent structures. Thirteen fresh-frozen ankle specimens were systematically dissected. Methylene blue solution was injected to identify the dimensions of the ankle capsule. External dimensions were measured as the distance from the capsular reflection to the bony margin of the ankle. Internal dimensions were measured as the distance from the capsular attachment of the distal tibia, fibula, and talus to the cartilage margin. The anterior aspect of the capsule demonstrated the most proximal capsular reflection in all specimens. The most proximal reflections of the anteromedial, anterior middle and anterolateral capsule were 10.3, 13.5, and 9.8 mm, respectively. The most proximal reflections of the posteromedial, posterior middle and posterolateral region were 8.7, 6.2, and 3.5 mm, respectively. There was no capsular reflection over the medial malleolus and less than 1 mm over the posterior lateral malleolus. There was a confluence of the capsule and ligamentous complex on the medial side, and also with the transverse tibiofibular ligament about the posterolateral ankle. The most proximal attachment of the ankle capsule was located at the anterior aspect of the distal tibia. The medial and posterolateral capsules were confluent with the ligamentous complexes of the ankle in those regions. Clin. Anat. 31:1018-1023, 2018. © 2018 Wiley Periodicals, Inc.

A new method for achieving compression in hindfoot arthrodesis.

BACKGROUND: When performing hindfoot arthodeses, one goal of fixation is often to achieve compression across the joint. Traditional lag screws are applied eccentrically, providing compression more on the edge of the fusion. A new technique, using a post in one bone and a lag screw through the post to the other bone, may offer better compression across more of the joint. METHODS: There are three parts to this study comparing a post-and-screw construct to traditional lag screws. Synthetic bone models, representative of the talonavicular joint, were created and assessed for biomechanical measures of compression. Next, the post-and-screw construct was tested in cadavers, under conditions representing early weight bearing after arthrodesis surgery. Finally, 18 patients who had a talonavicular fusion with a post-and-screw construct with one surgeon were compared to the previous 18 patients fixed with traditional screws. RESULTS: In the synthetic bone model, the post-and-screw construct brought the centre of compression closer to the centre of the joint, suggesting compression was less eccentric. Neither traditional screws nor the post-and-screw construct were sufficiently strong to resist early weight bearing forces in cadaver specimens. In the clinical comparison, four patients had a painful nonunion when fixed with traditional screws, compared to none in the post-and-screw construct. CONCLUSIONS: A post-and-screw construct spreads the forces of compression more uniformly across an arthrodesis, even when placed eccentrically. Although not all the biomechanical measures were superior, the post-and-screw construct achieved higher levels of successful fusion in patients. This technology may offer improved outcomes in some clinical scenarios and deserves further study. LEVEL OF EVIDENCE: Level 3.

Arthroscopic assessment of medial malleolar reduction.

INTRODUCTION: Ankle fractures treated with open reduction internal fixation are fixed in an effort to reestablish anatomic bony alignment and avoid a malunion, thereby diminishing the risk of post-traumatic arthritis. For a medial malleolar fracture, an articular step-off is likely more related to the risk of post-traumatic arthritis than is a cortical step-off. However, the external cortical alignment is often used to judge the adequacy of reduction, as the articular component of the fracture is not as readily visualized. Arthroscopy has been used in various articular fractures as an aid to diagnosis and treatment. The current study prospectively assessed both the quality of medial malleolar reduction on the articular side using arthroscopy and the adequacy of using cortical cues to guide the articular reduction. METHODS: Twelve consecutive patients were enrolled in this prospective diagnostic study. All patients had medial malleolar fractures that required fixation. The outcome variables of interest were extra-articular fracture displacement and articular surface displacement. RESULTS: After reduction and provisional fixation, 10 of the 12 patients had an anatomic reduction based on cortical cues. On arthroscopy 7 of the 12 patients had an anatomic reduction. Four of the patients had a slight gap (<1 mm) at the anterior edge of the fracture. The last patient had an anterior gap just under 2 mm. Two patients had impaction of the medial malleolus that made reduction difficult and was recognized during arthroscopy after obtaining a reduction based on cortical cues. CONCLUSION: The cortical reduction of the medial malleolus often matched up with the articular reduction. However, in some patients, impaction of the medial malleolus made it so that the two did not match up. There are some cases in which extra-articular cues are insufficient to evaluate for intra-articular reduction.

Diagnostic Imaging for Achilles Tendinopathy: Unnecessary Scans? Valuable Insights? Multidisciplinary Clinician-Scientists Present a Nuanced View.

SYNOPSIS: Clinical practice guidelines for Achilles tendinopathy do not recommend imaging to inform diagnosis. However, there is considerable variation in how imaging is used, particularly in research and sports. Early imaging risks that people who see the images presume that what they "see" as pathology is the primary cause of pain; patients might end up receiving invasive treatments on the basis of the image when rehabilitation may suffice. On the other hand, imaging can help rule out Achilles tendinopathy and identify differential diagnoses. As more rehabilitation clinicians are direct access practitioners and take on expanded roles as primary health practitioners, ultrasound imaging might serve as a valuable point-of-care tool for diagnosis, identifying conditions that warrant referral and managing conditions like Achilles tendinopathy. We argue that the value of ultrasound imaging to diagnose tendinopathy outweighs the potential limitations. J Orthop Sports Phys Ther 2024;54(1):1-4. Epub 16 November 2023. doi:10.2519/jospt.2023.12255.

Achilles tendon rupture in women.

BACKGROUND: The incidence of Achilles rupture appears to be less in women, although this notion has not been specifically investigated in the literature. METHODS: The medical records of 7 foot-and-ankle orthopaedic surgeons at 1 institution were reviewed by Current Procedural Terminology (code 27650) and International Classification of Diseases-9 (code 727.67) to establish all Achilles tendon ruptures seen and/or treated by these surgeons. Sex, age, side, and mechanism of injury were recorded. Whether the patient had an acute Achilles tendon rupture or nonacute Achilles pathology was also noted. RESULTS: A total of 468 patients were identified, of whom 358 had acute ruptures: 302 male and 56 female (5.39:1). Patients with acute ruptures were significantly younger than those with nonacute pathology (43.8 vs 55.1, P < .001). For acute ruptures, the mean age was not significantly different between men and women (43.9 vs 43.2; P = .780). Athletic activity was causative in 243 of 302 men (80.5%) and in 40 of 56 women (71.4%). This difference was not statistically significant (P = .130). Six men (2.0%) and 6 women (10.7%) had comorbidities that were thought to increase their risk of rupture (P = .005). CONCLUSION: Achilles tendon rupture is more common in men than women. Previous studies using the aforementioned codes to identify patients without chart review may have overestimated the number of women with acute Achilles tendon rupture. LEVEL OF EVIDENCE: Level III, retrospective comparative series.

Republication of "Evidence Versus Practice: Operative Treatment Preferences in Hallux Valgus".

Background: There is substantial variability in the operative treatment of hallux valgus despite the existence of high quality evidence to guide treatment decisions. The purpose of this study was to determine the current trends in the treatment of mild, moderate, and severe hallux valgus and if greater degrees of consensus correlate with the presence of higher-level evidence. Methods: Members of the American Orthopaedic Foot & Ankle Society completed a 14-item survey. A total of 131 (14%) of 922 members completed the survey. Three cases representing 3 stages of HV were presented, and respondents selected their preferred treatment. Preferred forms of proximal and distal metatarsal osteotomies, as well as mode of fixation for each, were inquired. Results: In the treatment of mild hallux valgus without second metatarsalgia, 80% of those surveyed chose a distal metatarsal osteotomy, while, if second metatarsalgia was present, 56% chose a distal metatarsal osteotomy with a second metatarsal-shortening osteotomy. In the treatment of moderate hallux valgus, there was generally less consensus, while, in the treatment of severe hallux valgus, a majority of those surveyed chose a Lapidus procedure, with the addition of a second metatarsal-shortening osteotomy in the presence of second metatarsalgia. The most popular distal and proximal metatarsal osteotomies, respectively, were chevron osteotomy (80%) and opening wedge osteotomy (33%). The presence of Level I evidence did not significantly correlate with higher degrees of consensus. Conclusion: Despite the existence of high-quality evidence supporting the use of certain procedures in the treatment of HV, there exists an apparent lack of consensus among surgeons about the choice of surgical procedures. Moreover, higher-level evidence was not correlated with greater consensus in hallux valgus. Level of Evidence: Level II.

Defining Operative Indications in Lisfranc Injuries: A Systematic Review.

OBJECTIVE: The aim of this review was to determine operative indications for Lisfranc injuries. METHODS: A systematic review using a MEDLINE literature search was performed using the index "Lisfranc Injury" from 1980 onward using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines where applicable. Inclusion criteria were all clinical studies reporting on the management of Lisfranc injuries obtained via the search index, including case reports, review articles, cohort studies, and randomized trials. Non-English-language articles, inaccessible articles, those not relevant to the management of Lisfranc injuries (biomechanical, cadaveric, and technique articles), and those that did not explicitly state operative indications (vague or absent indications) were excluded. RESULTS: After identifying 737 studies, the full text of 391 studies was reviewed, and 58 reports providing explicit operative indications were included in the final analysis. Fifty-one (81.1%) studies provided diastasis cutoffs varying ≥2 mm (35/58; 60.4%), ≥1 mm (13; 22.4%), and ≥3 mm (3; 5.2%); the diastasis location was most commonly unspecified (31/58; 53.5%) or varied between combinations of metatarsal, tarsal, cuboid, and cuneiform bones (20/58; 27.6%). Specific imaging criteria for surgery included an avulsion fracture or fleck sign (3/58; 5.2%), arch height loss (3/58; 5.2%), and a tear on magnetic resonance imaging (5; 8.6%). The 11 (19%) studies defining operative indications in terms of classification schemes used the Nunley and Vertullo (8/58; 13.8%), Myerson (2; 3.5%), and Buehren (1; 1.7%) systems. Twenty-one (36.2%) studies provided multiple operative indications. CONCLUSION: The most common Lisfranc operative indications among the limited reporting studies varied from a 1- to 3-mm diastasis across several locations. It is imperative for operative indications to be reported with an increased frequency and in a homogenous fashion to guide the clinical management of these subtle injuries. LEVELS OF EVIDENCE: Level IV; systematic Review.