Critical Analysis of Retrospective Study Designs: Cohort and Case Series.

Retrospective studies represent an often used research methodology in the podiatric scientific literature, with cohort studies and case series being two of the most prevalent designs. Choosing a retrospective method is often dependent on multiple factors, two of the most important being details of the research question to be explored and the sample size that can be acquired. When analyzing literature, a reader must understand how retrospective studies work to critically examine the methods, results, and discussions to determine if the conclusion is reasonable and might be applied to clinical practice.

First Tarsometatarsal Joint Arthrodesis for Hallux Valgus With and Without Intermetatarsal Screw Fixation: A Comparison of Correction and Maintenance of Correction.

Tarsometatarsal joint arthrodesis is a commonly accepted procedure for hallux valgus associated with severe deformity and first ray hypermobility or medial column instability. This study evaluates the correction of hallux valgus deformity and the maintenance of correction with and without the use of a stabilization screw between the first and second metatarsal bases. Through retrospective review of first tarsometatarsal joint arthrodesis within our institution we evaluated 63 patients. Twenty-seven patients did not have a first to second metatarsal base screw and were placed into the no screw cohort. Thirty-six patients did have a first to second metatarsal base screw and were placed into the screw cohort. This study population had an osseous union rate of 95%. Clinical and radiographic recurrence occurred in 5 of 63 patients (8%). At 1-y postop the measurements demonstrated that the screw cohort had an average intermetatarsal angle correction of 11.6 degrees while the no screw cohort had an average correction of 7.8 degrees. Additionally, at 1-y postop the screw cohort had greater maintenance of the intermetatarsal angle correction with an average change of 0.5 degrees compared to 2.3 degrees in the no screw cohort. We conclude that the addition of the stabilization screw improves the first tarsometatarsal joint arthrodesis construct resulting in a greater degree of realignment and maintenance of correction.

Radiographic Outcomes of Talonavicular Joint Arthrodesis With Varying Fixation Techniques in Stage III Adult Acquired Flatfoot Reconstruction.

Utilization of the talonavicular joint (TN) arthrodesis as an isolated procedure or in combination with hindfoot arthrodesis has been described in the literature for treatment of numerous hindfoot conditions. When used in isolation or with concomitant hindfoot arthrodesis, the TN joint has demonstrated nonunion rates reported as high as 37% in the literature. Despite previous research, there remains a lack of agreement upon the ideal fixation technique for TN joint arthrodesis with and without concomitant subtalar joint arthrodesis. The purpose of this study was to retrospectively compare the radiographic and clinical results of TN joint arthrodesis as part of double arthrodesis procedure utilizing 4 separate fixation constructs in the treatment of advanced hindfoot malalignment in stage III adult-acquired flatfoot deformity. We retrospectively reviewed 105 patients who underwent TN joint arthrodesis as part of double arthrodesis procedure utilizing 4 separate fixation constructs. Our results demonstrated a nonunion rate of 16.2%, with 17 nonunions identified within our patient population. One (2.4%) nonunion was observed in the 3-screw cohort, 7 (33.3%) nonunions were observed in the 2-screw cohort, 4 (16.0%) nonunions were observed in the 2-screw plus plate cohort, and 5 (29.4%) nonunions were observed in the 1-screw plus plate cohort. The difference in nonunion rate between the 4 cohorts was statistically significant. Based on these results, we conclude that the use of a 3-screw construct for TN joint arthrodesis as part of double arthrodesis procedure demonstrates a statistically significant reduction in nonunion rate and should be considered a superior fixation construct for this procedure.

Effect of the First Tarsometatarsal (Modified Lapidus) Arthrodesis on Hindfoot Alignment.

The purpose of this study is to demonstrate the effect of first tarsometatarsal (modified Lapidus) arthrodesis on hindfoot alignment. We reviewed the radiographs of 39 patients, 40 feet (16 right feet and 24 left feet in 6 males and 34 females; mean age 43 years) who underwent hallux valgus reconstruction and isolated first tarsometatarsal arthrodesis. Patients who had ancillary osseous procedures were excluded from the study, with the exception of proximal phalangeal osteotomy to address hallux interphalangeus. The mean time to follow up was 33.78 weeks (8.45 months), median 21.5 weeks. Statistically significant differences were found between preoperative and postoperative measurements for talar declination (-3.3 ± 3.5), lateral talocalcaneal angle (-3.1 ± 3.9), lateral Meary's angle (-4.2 ± 4.9), medial cuneiform height (3.5 ± 4.6), medial cuneiform to fifth metatarsal distance (4.7 ± 4.5), AP talocalcaneal angle (-2.8 ± 5.3), and percentage of talar head uncovering (-6.6 ± 7.6). Our results suggest that first tarsometatarsal arthrodesis can affect hindfoot alignment on AP and lateral radiographs.

A Multicenter, Retrospective, Case Series of Patients With Charcot Neuroarthropathy Deformities Undergoing Arthrodesis Utilizing Recombinant Human Platelet-derived Growth Factor With Beta-Tricalcium Phosphate.

Charcot neuroarthropathy has traditionally been treated using both nonsurgical and surgical strategies. Recently, orthobiologics have been used to promote arthrodesis in Charcot reconstructions, obviating the need for bone graft in some cases. Recombinant human platelet-derived growth factor BB homodimer (rhPDGF-BB) in combination with beta-tricalcium phosphate scaffold (ß-TCP) is a bone graft substitute shown to have comparable efficacy to autograft in incidence of foot and ankle fusion. This multicenter, consecutive case series analyzed patients undergoing Charcot reconstructions utilizing rhPDGF-BB/ß-TCP for joint fusion. In this cohort, 98 patients (62.24% male) with a mean age of 62.82 ± 10.28 years (range 40-87) had a fusion incidence of 217 of 223 joints (97.31%) with a mean time to fusion of 13.09 ± 4.87 weeks (range 6-30). There were 6 nonunions in the patient population. Fusion was defined as ≥50% osseous bridging based on computed tomography and/or radiographic consolidation, in addition to clinical findings. With an overall complication rate of 26.53% (26/98), adverse events occurring in more than 1 patient limb included hardware failures (n = 7, 7.14%), infection (n = 4, 4.08%), wound dehiscence (n = 4, 4.08%), amputation (n = 3, 3.06%), and death (n = 2, 2.04%). There were no adverse events related to the grafting material. From this review, we found rhPDGF-BB/ß-TCP to be a safe and effective graft material that can be considered a viable alternative to autograft, even in high-risk patients such as those with Charcot neuroarthropathy.

Primary Arthrodesis of the Tibiotalar Joint in Severely Comminuted High-Energy Pilon Fractures.

BACKGROUND: The treatment of highly comminuted tibial pilon fractures is controversial. The aim of this study was to determine the effectiveness and outcomes of primary arthrodesis following highly comminuted tibial plafond fractures. METHODS: A database search was performed to identify all patients who underwent blade plate arthrodesis at our institution over a sixteen-year period. Inclusion criteria included patients with an Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association type-C2 or type-C3 pilon fracture that was deemed to be non-reconstructable by the treating surgeon. Outcomes were measured using the Short-Form 36-Item Health Survey, time to independent walking, time to consolidation of the arthrodesis, and wound-healing complications. RESULTS: A total of twenty patients were included in this study, and seventeen patients (85%) were available for follow-up at a minimum of two years after their surgery. Wound infections or wound dehiscence did not occur in this series. All patients were walking without crutches or a walker at their latest follow-up. One patient developed an aseptic nonunion and healed successfully after revision surgery. CONCLUSIONS: Blade plate ankle fusion using a posterior approach is a reliable method for the treatment of a small subset of patients with severely comminuted, non-reconstructable pilon fractures. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Advancements in percutaneous fixation for foot and ankle trauma.

Operative fixation of foot and ankle trauma can be challenging. Often times, the soft tissue envelope can have extensive damage as a result of the fracture. In these cases, percutaneous fixation may be used. Percutaneous fixation can benefit both soft tissue and osseous healing when used correctly. Many techniques have been described in the literature that may help to preserve blood supply, minimize soft tissue dissection, and restore a functional limb. This article reviews general guidelines for fracture and soft tissue management, osseous healing of fractures, and how certain techniques influence fracture healing. It also illustrates certain techniques for specific fracture reduction.

Surgical site infections after foot and ankle surgery: a comparison of patients with and without diabetes.

OBJECTIVE: This prospective study was designed to evaluate the rate of surgical site infection (SSI) after foot and ankle surgery in patients with and without diabetes. RESEARCH DESIGN AND METHODS: The study prospectively evaluated 1,465 consecutive foot and ankle surgical cases performed by a single surgeon. RESULTS: The overall SSI rate in this study was 3.5%, with significantly more infections occurring in individuals with diabetes than in those without (9.5 vs. 2.4%, P < 0.001). Peripheral neuropathy, Charcot neuroarthropathy, current or past smoking, and increasing length of surgery were significantly associated with SSI on multivariate analysis. CONCLUSIONS: This study demonstrates significant associations between the development of SSI and chronic complications of diabetes. We confirm previous findings that it is peripheral neuropathy and not diabetes itself that most strongly determines the development of postoperative infections in these surgical patients.

Postoperative infection rates in foot and ankle surgery: a comparison of patients with and without diabetes mellitus.

BACKGROUND: Patients with diabetes mellitus may be at increased risk for infection following foot and ankle surgery. This study aimed to determine whether patients with a diagnosis of diabetes mellitus have an increased rate of infection following foot and ankle surgery compared with a cohort of patients without diabetes. Furthermore, our study sought to demonstrate whether patients with complicated diabetes are at greater risk of postoperative wound infection than are patients with uncomplicated diabetes or patients without diabetes. METHODS: We conducted a retrospective review of the charts of 1000 patients who had orthopaedic foot and ankle surgery. The following data were extracted: patient age, sex, history of diabetes mellitus, development of postoperative infection, severity of infection, inpatient or outpatient surgery, use of internal or external fixation, tobacco use, history of organ transplantation, history of rheumatoid arthritis, length of surgery, follow-up time in weeks, and comorbid conditions. RESULTS: The overall infection rate in this study was 4.8%. Fifty-two percent of all infections occurred in our diabetic study group, which represented only 19% of the patient population. Postoperative infections occurred in significantly more persons with diabetes (13.2%) than in those without diabetes (2.8%). Diabetic patients were five times more likely to experience a severe infection requiring hospitalization compared with patients without diabetes. After removing the patients with neuropathy from the analysis, there was no longer a significant association between diabetes and infection. The presence of complicated diabetes increased the risk of postoperative infection by a factor of ten compared with the risk for patients without diabetes and by a factor of six compared with the risk for patients with uncomplicated diabetes. We did not identify a significantly increased risk of infection in patients with uncomplicated diabetes compared with that in patients without diabetes. CONCLUSIONS: Patients with diabetes mellitus are at increased risk of severe infection compared with those without diabetes. Patients with uncomplicated diabetes did not have an increased risk of postoperative infection compared with patients without diabetes, whereas patients with complicated diabetes had a significantly higher rate of postoperative infection.