Spring Ligament Reconstruction for Progressive Collapsing Foot Deformity: Contemporary Review.

The spring ligament is one of the main stabilizers of the medial arch of the foot and the primary static supporter of the talonavicular joint. Attenuation or rupture of this ligament is thought to play a central role in the pathophysiology of progressive collapsing foot deformity. Traditional correction of flexible flatfoot consists of posterior tibial tendon augmentation along with various osteotomies or hindfoot fusions. Repair or reconstruction of the spring ligament has not been as widely pursued. In recent years, newer techniques have been explored and may improve outcomes of traditional procedures, or possibly entirely replace some osteotomies. Combined spring-deltoid ligament reconstruction is also gaining traction as a viable technique, particularly as the ankle begins to deform into valgus. This review summarizes the variety of nonanatomic and anatomic reconstruction techniques that have been described, including autologous tendon transfers, allografts, and synthetic augmentation. Although many have only been characterized in biomechanical cadaver studies, this article reviews preliminary clinical studies that have shown promising results. There is a need for more high-quality studies evaluating the clinical, radiographic, and patient-reported outcomes following spring ligament reconstruction.

Contemporary Review: An Overview of the Utility of Patient-Reported Outcome Measurement Information System (PROMIS) in Foot and Ankle Surgery.

Patient-Reported Outcome Measurement Information System (PROMIS) has favorable psychometric and administrative properties in orthopaedic clinical research. It facilitates clinically meaningful data collection while minimizing administration time and survey fatigue and improving compliance. PROMIS is a critical component of patient-centered care and shared decision making, as it provides enhanced communication and engagement between patients and providers. As a validated instrument, it may also aid in measuring value-based health care quality. The goal of the current work is to provide an overview of PROMIS metrics used in orthopaedic foot and ankle, including advantages and disadvantages compared to legacy scales and PROMIS's applicability in specific foot and ankle conditions based on psychometric properties. We provide a review of the literature regarding the utilization of PROMIS as an outcome measure for specific foot and ankle procedures and conditions.

Application of the Mayo Periprosthetic Joint Infection Risk Score for Total Ankle Arthroplasty.

BACKGROUND: Assessing patient's risk of infection is fundamental for prevention of periprosthetic joint infection (PJI) after total ankle arthroplasty (TAA). The Mayo Prosthetic Joint Infection Risk Score (Mayo Score) is based on data from total hip and knee arthroplasty and has not been validated for application for TAA. METHODS: A total of 405 consecutive TAA cases were followed for 6 months for PJI. Individual patients' Mayo Scores were calculated and analyzed with logistic regression and receiver operating characteristic (ROC) for predictability for PJI. A critical cut-off Mayo Score for patients at high risk of PJI was determined by best Youden index. Among the Mayo Score-defined high-risk patients, the contribution of different risk factors were compared between the PJI and non-PJI patients. RESULTS: There were 10 cases of PJI (2.5%) among the 405 cases within 6 months after TAA. Of the 405 patients, the Mayo Scores ranged between -4 and 13 (median 2; interquartile range 0-5). The average Mayo Score was 2.5 ± 3.4 in the non-PJI patients and 7.7 ± 3.1 in the PJI patients (P < .001). Logistic regression showed that the probability of PJI increased with higher Mayo Scores (odds ratio 1.48, 95% CI 1.23-1.78). All but 1 PJI patients had a Mayo Score >5. The sensitivity and specificity were 90.0% and 84.3%, respectively, when a Mayo Score >5 was used as a criterion for high risk of PJI. CONCLUSION: This study demonstrated that the Mayo Score could similarly predict PJI risk after TAA as in total hip and knee arthroplasty. Data analysis suggests that a Mayo Score >5 could be a criterion for identifying high-risk patients for PJI, although further validation with a large number of PJI cases is necessary. LEVEL OF EVIDENCE: Level II, developing diagnositic criteria with consecutive cases.

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.

Are SER-II Ankle Fractures Anatomic? Computed Tomography Demonstrates Mortise Malalignment in the Setting of Apparently Normal Radiographs.

BACKGROUND: Ankle fracture treatment is predicated on minimal displacement, leading to abnormal joint contact area. The purpose of this investigation is to determine whether computed tomography (CT) detects subtle mortise malalignment undetectable by x-ray in supination-external rotation-II (SER-II) injuries. METHODS: A total of 24 patients with SER-II injuries, as demonstrated by negative gravity stress radiography, were included. Medial clear space (MCS) measurements were performed on bilateral ankle x-rays (injured and contralateral, uninjured side) at several time points as well as bilateral non-weight-bearing CT performed once clinical and radiographic healing was demonstrated (mean = 66 days post injury, range = 61-105 days). Statistical analyses examined differences in measurements between both sides. RESULTS: Final x-rays demonstrated no differences between normal and injured ankle MCS (P = .441). However, CT coronal/axial MCS measurements were different (P < .05). CT coronal MCS measured wider by a mean difference of 0.67 mm (P < .001). CONCLUSION: There is a high incidence of subtle mortise malalignment in SER-II ankle fractures, as demonstrated by CT, which is undetectable when assessed by plain radiographs. Although clinical outcomes are yet unknown, there are important implications of the finding of confirmed, subtle mortise malalignment in SER-II injuries and the limitations of x-ray to detect it. LEVEL OF EVIDENCE: Level III.

The Mini C-Arm Sock: A Novel and Simple Technique for Draping to Prevent Contamination and Penetration.

The mini C-arm is frequently used in foot and ankle surgery. However, its continuous manipulation introduces potential means of contaminating the sterile surgical field. A simple and effective draping technique of the mini C-arm is described to minimize risk of contamination and sharps penetration that can damage the C-arm. Levels of Evidence: Level V.

Prophylactic Fixation Can Be Cost-effective in Preventing a Contralateral Bisphosphonate-associated Femur Fracture.

BACKGROUND: Bisphosphonates reduce the risk of fractures associated with osteoporosis but increase the risk of atypical subtrochanteric femur fractures. After unilateral atypical femur fracture, there is risk of contralateral fracture, but the indications for prophylactic fixation are controversial. QUESTIONS/PURPOSES: The purpose of this study is to use Markov modeling to determine whether contralateral prophylactic femur fracture fixation is cost-effective after a bisphosphonate-associated atypical femur fracture and, if so, what patient-related factors may influence that determination. METHODS: Markov modeling was used to determine the cost-effectiveness of contralateral prophylactic fixation after an initial atypical femur fracture. Simulated patients aged 60 to 90 years were included and separated into standard and high fracture risk cohorts. Patients with standard fracture risk were defined as those presenting with one atypical femur fracture but without symptoms or findings in the contralateral femur, whereas patients with high fracture risk were typified as those with more than one risk factor, including Asian ethnicity, prodromal pain, femoral geometry changes, or radiographic findings in the contralateral femur. Outcome probabilities and utilities were derived from studies matching to patient characteristics, and fragility fracture literature was used when atypical femur fracture data were not available. Associated costs were largely derived from Medicare 2015 reimbursement rates. Sensitivity analysis was performed on all model parameters within defined ranges. RESULTS: Prophylactic fixation for a 70-year-old patient with standard risk for fracture costs USD 131,300/quality-adjusted life-year (QALY) and for high-risk patients costs USD 22,400/QALY. Sensitivity analysis revealed that prophylaxis for high-risk patients is cost-effective at USD 100,000/QALY when the cost of prophylaxis was less than USD 29,400, the probability of prophylaxis complications was less than 21%, or if the patient was younger than 89 years old. The parameters to which the model was most sensitive were the cost of prophylaxis, patient age, and probability of prophylaxis-related complications. CONCLUSIONS: Prophylactic fixation of the contralateral side after unilateral atypical femur fracture is not cost-effective for standard-risk patients but is cost-effective among high-risk patients between 60 and 89 years of age with a high risk for an atypical femur fracture defined by patients with more than one risk factor such as Asian ethnicity, prodromal pain, varus proximal femur geometry, femoral bowing, or radiographic changes such as periosteal beaking and a transverse radiolucent line. However, our findings are based on several key assumptions for modeling such as the probability of fractures and complications, the costs associated for each health state, and the risks of surgical treatment. Future research should prospectively evaluate the degree of risk contributed by known radiographic and demographic parameters to guide management of the contralateral femur after a patient presents with an atypical femur fracture. LEVEL OF EVIDENCE: Level III, economic and decision analyses.

Does the quality of preoperative closed reduction of displaced ankle fractures affect wound complications after surgical fixation?

BACKGROUND: Displaced ankle fractures are initially closed reduced and splinted with the goal of restoring gross ankle alignment. The benefits of an exact closed reduction are unclear and possibly detrimental and unnecessary if multiple attempts are made. The purpose of this study was to determine whether the quality of preoperative closed reduction in patients with operative ankle fractures affects post-operative wound complications. METHODS: A retrospective analysis was performed of patients with isolated, closed, operative ankle fractures treated at two level 1 trauma centers who had an initial closed reduction performed on presentation. Patient demographics, fracture characteristics, data pertinent to the reduction, and post-operative wound complications were collected. A novel grading system to assess reduction quality was developed, applied, and evaluated for inter- and intra-observer agreement. RESULTS: 161 patients met inclusion criteria for analysis. 17% (27/161) sustained a post-operative wound complication. There was no statistically significant association between wound complications and quality of preoperative closed reduction (p = 0.17) nor with multiple reduction attempts (p = 0.887). However, patients with poor initial reductions had a decreased mean time to surgery (1.4 ± 2.9 versus 4.7 ± 6.3 days, p = 0.03), which may have been protective. Interclass correlation coefficients for inter- and intra-rater reliability of the classification schema was 0.942 and 0.922, respectively, demonstrating excellent agreement. CONCLUSION: There was no association between preoperative closed reduction quality and incidence of post-surgical wound complications in patients with operative ankle fractures when analyzing the variables assessed in this investigation. While initial ankle reduction is still recommended, multiple attempts to achieve a perfect reduction are likely unnecessary.

Venous Thromboembolism Disease Prophylaxis in Foot and Ankle Surgery.

There are limited data to guide the use of venous thromboembolism disease (VTED) prophylaxis after foot and ankle surgery. Although there is general consensus that the overall risk is lower than after hip or knee replacement, subpopulations of patients may be at relatively heightened risk. Furthermore, existing data are often conflicting regarding the efficacy of prophylaxis, with little acknowledgment of the tradeoffs between VTED prophylaxis and potential complications associated with the use of such medications. This article provides an overview of currently available evidence to guide decision making regarding VTED prophylaxis in patients who undergo foot and ankle surgery.

Glucocorticoid signaling in myeloid cells worsens acute CNS injury and inflammation.

Glucocorticoid stress hormones (GCs) are well known for being anti-inflammatory, but some reports suggest that GCs can also augment aspects of inflammation during acute brain injury. Because the GC receptor (GR) is ubiquitously expressed throughout the brain, it is difficult to know which cell types might mediate these unusual "proinflammatory" GC actions. We examined this with cell type-specific deletion or overexpression of GR in mice experiencing seizure or ischemia. Counter to their classical anti-inflammatory actions, GR signaling in myeloid cells increased Iba-1 and CD68 staining as well as nuclear p65 levels in the injured tissue. GCs also reduced levels of occludin, claudin 5, and caveolin 1, proteins central to blood-brain-barrier integrity; these effects required GR in endothelial cells. Finally, GCs compromised neuron survival, an effect mediated by GR in myeloid and endothelial cells to a greater extent than by neuronal GR.