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.

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.

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.

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.

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.

Currently used imaging options cannot accurately predict subtalar joint instability.

PURPOSE: To give a systematic overview of current diagnostic imaging options and surgical treatment for chronic subtalar joint instability. METHODS: A systematic literature search across the following sources was performed: PubMed, ScienceDirect, and SpringerLink. Twenty-three imaging studies and 19 outcome studies were included. The Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS 2) tool was used to assess the methodologic quality of the imaging articles, while the modified Coleman Score was used to assess the methodologic quality of the outcome studies. RESULTS: Conventional radiographs were most frequently used to assess chronic subtalar joint instability. Talar tilt, anterior talar translation, and subtalar tilt were the three most commonly used measurement methods. Surgery often included calcaneofibular ligament reconstruction. CONCLUSION: Current imaging options do not reliably predict subtalar joint instability. Distinction between chronic lateral ankle instability and subtalar joint instability remains challenging. Recognition of subtalar joint instability as an identifiable and treatable cause of ankle pain requires vigilant clinical investigation. LEVEL OF EVIDENCE: Systematic Review of Level III and Level IV Studies, Level IV.

Isolated avulsion fracture of the first metatarsal base at the peroneus longus tendon attachment: a case report.

Avulsion fractures of the first metatarsal (MT1) base at the peroneus longus (PL) tendon attachment are rare and may be undiagnosed during an emergency visit. If the injury is not treated properly, chronic pain or persistent impairment for inversion and plantar-flexion of the first ray may occur. This case report presents a 30-year-old woman who presented 10 weeks post trauma to a foot and ankle surgeon due to a swollen right midfoot with diffuse tenderness over the medial Lisfranc joint. Further evaluation showed an isolated avulsion fracture of the first metatarsal, which was undiagnosed during the emergent visit following the accident. In this case, the patient was successfully treated conservatively. The goal of this article is to raise awareness of this rare injury for radiologists and orthopedic surgeons.

Imaging in syndesmotic injury: a systematic literature review.

OBJECTIVES: To give a systematic overview of current diagnostic imaging options for assessment of the distal tibio-fibular syndesmosis. MATERIALS AND METHODS: A systematic literature search across the following sources was performed: PubMed, ScienceDirect, Google Scholar, and SpringerLink. Forty-two articles were included and subdivided into three groups: group one consists of studies using conventional radiographs (22 articles), group two includes studies using computed tomography (CT) scans (15 articles), and group three comprises studies using magnet resonance imaging (MRI, 9 articles).The following data were extracted: imaging modality, measurement method, number of participants and ankles included, average age of participants, sensitivity, specificity, and accuracy of the measurement technique. The Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool was used to assess the methodological quality. RESULTS: The three most common techniques used for assessment of the syndesmosis in conventional radiographs are the tibio-fibular clear space (TFCS), the tibio-fibular overlap (TFO), and the medial clear space (MCS). Regarding CT scans, the tibio-fibular width (axial images) was most commonly used. Most of the MRI studies used direct assessment of syndesmotic integrity. Overall, the included studies show low probability of bias and are applicable in daily practice. CONCLUSIONS: Conventional radiographs cannot predict syndesmotic injuries reliably. CT scans outperform plain radiographs in detecting syndesmotic mal-reduction. Additionally, the syndesmotic interval can be assessed in greater detail by CT. MRI measurements achieve a sensitivity and specificity of nearly 100%; however, correlating MRI findings with patients' complaints is difficult, and utility with subtle syndesmotic instability needs further investigation. Overall, the methodological quality of these studies was satisfactory.