Category: Hindfoot; Ankle; Midfoot/Forefoot Introduction/Purpose: Optimization of articular joint coverage has been shown to decrease the progression of arthritic degeneration and to improve outcomes in patients with hip and shoulder pathologies. Progressive Collapsing Foot Deformity (PCFD), previously known as Adult-Acquired Flatfoot Deformity, has been demonstrated to advance with peritalar subluxation (PTS), progressively decreased articular coverage of the subtalar joint articular facets (anterior, middle, and posterior), as well as the development of sinus tarsi and subfibular impingements. Outcome assessment in PCFD has focused on improving conventional radiographic measurements such as the talus-first metatarsal angle and the hindfoot moment arm. This study aimed to evaluate improvements of PTS, subtalar joint articular coverage, and extra-articular impingement following PCFD joint-sparing surgical treatment, as well as the influence of these improvements in patient-reported outcomes. Methods: IRB-approved prospective comparative study. Adult PCFD patients that failed conservative treatment for three-months and underwent hindfoot joint-sparing surgical procedures by a single-surgeon were enrolled. Realignment soft-tissue and bony procedures performed were recorded. All patients underwent Weight Bearing CT (WBCT) preoperatively, and at the 3- and 12- months follow-up. Two observers performed traditional WBCT PCFD measurements. The foot bones were segmented, and distance measurements were performed along the entire 3D superior surface of the calcaneus, including the subtalar joint (SJ) articular facets (anterior, middle, and posterior), sinus tarsi and subfibular area. Color-coded coverage maps (CM) were calculated to grade the amount of articular joint coverage and extra-articular impingement. Patient Reported Outcomes (PROs) were recorded at all follow-up time-points. Pre- and postoperative measurements were compared by paired T-Tests/Wilcoxon and a Multivariate regression analysis was utilized to assess the influence of improvements of articular coverage and impingement in PROs. Results: Twenty patients were included (15F/5M), mean age, BMI, and follow-up of respectively 48.1 (22 to 72) years, 33.88 (23.8 to 46.8) kg/m2, and 13.2 (4 to 27) months. Significant improvements in all traditional PCFD WBCT measurements were noted postoperatively. Articular coverage (CM) of the SJ middle and anterior facets improved postoperatively by respectively 13.5% (p=0.02) and 78% (p=0.001). Similarly, improvement in sinus tarsi impingement, with a 69% decrease in sinus tarsi coverage was observed (p<0.001). Significant PROs improvements were also noted, with Pain Catastrophizing Score (PCS) improving from 13.4 to 5.2 (p=0.0032) and the European Foot and Ankle Score (EFAS) from 6 to 8.5 (p=0.036). Improvements in PROs for PCS and EFAS were explained its majority by improvement in SJ articular coverage and sinus tarsi impingement, with R2 values of respectively 84% and 92% for PCS and EFAS. Conclusion: Peritalar subluxation (PTS) is an important marker of Progressive Collapsing Foot Deformity (PCFD). To the author's knowledge, this is the first time that 3D articular coverage maps were utilized to assess deformity correction following surgical treatment in PCFD. We found significant improvements in the subtalar joint (SJ) anterior and middle facet articular coverage as well as significantly decreased sinus tarsi and subfibular impingement. Most importantly, we found that PTS and SJ articular coverage improvements were the most important variables to influence Patient-Reported Outcomes. Three-dimensional evaluation of PTS and joint coverage can hopefully optimize treatment and improve outcomes in PCFD.
Category: Midfoot/Forefoot; Bunion Introduction/Purpose: Kim et al.'s simulated weight-bearing CT (WBCT) investigation classifying first metatarsal (M1) pronation and its relationship to the metatarso-sesamoid complex suggested a high prevalence (87.3%) of M1 hyper-pronation in hallux valgus (HV). These authors' conclusions have prompted a marked increase in M1 derotation (supination) in HV surgical correction. No subsequent study confirms their M1 pronation values, and two recent WBCT investigations suggest lower normative M1 pronation values. The objectives of our WBCT study were to (1) determine M1 pronation distribution in HV, (2) define the hyperpronation prevalence compared to preexisting normative values, and (3) assess the relationship of M1 pronation to the metatarso-sesamoid complex. We hypothesized identifying a high HV M1 head pronation distribution, but not as high as suggested by Kim et al. Methods: We retrospectively identified 88 consecutive feet with HV in our WBCT dataset and measured M1 pronation with two previously validated methods, the Metatarsal Pronation (MPA) and α angles. Similarly, using two previously published methods defining the pathologic pronation threshold, we assessed our cohort's M1 hyper-pronation prevalence, specifically (1) the upper value of the 95% confidence interval (CI95) and (2) adding 2 standard deviations at the mean normative value (2SD).The position of the sesamoids relative to the crista on the axial plane (sesamoid grading) was assessed according to Talbot et al. classification secondarily adapted by Yildirim et al. on CT scan (Figure).Normality of different variables was assessed using the Shapiro-Wilk test and distribution histogram. Two groups were compared using Student's t-test for normal, and Mann-Whitney U test for non- normal variables. P values less than .05 were considered significant. Results: The mean MPA was 11.4+/-7.4 degrees (IC95%:9.9-13.0; Range: -2.3-37.1) in our HV population and the α angle was 16.2+/-7.4 degrees (IC95%:14.7-17.7; Range: 2.8-43.2). A strong positive correlation was found between these two variables (ρ=0.82;r2=0.79;P<.001). According to the CI95 method, 69/88 HV (78.4%) were hyperpronated using the MPA, and 81/88 HV (92%) using the α angle. According to the 2SD method, 17/88 HV (19.3%) were hyperpronated using the MPA, and 20/88 HV (22.7%) using the α angle. There was a significant difference in M1 head pronation among sesamoid gradings (P=.025). Comparing HV sesamoid grade 3 to HV sesamoid grade 2 did not show any significant difference (P=.6). HV sesamoid grade 2 presented a decrease in MPA compared to HV sesamoid grade 1 (respectively 7.8+/-3.7 degrees for grade 2 and 10.8+/-4.9 degrees for grade 1,P=.026). Comparing HV sesamoid grade 1 to HV sesamoid grade 0 did not show any significant difference (P=.11). Conclusion: M1 head pronation distribution in HV was higher than in normative values, but threshold change demonstrated contradictory hyper-pronation prevalences (85% to 20%), calling into question the previously reported high prevalence of M1 hyper-pronation in HV. An increase in sesamoid subluxation was associated with a paradoxical decrease in M1 head pronation in our study. We suggest that a greater understanding of the impact of HV M1 pronation is warranted before routine axial plane M1 derotation (supination) is recommended for patients with HV.
Category: Sports; Ankle Introduction/Purpose: The number of professional and amateur athletes has increased, consequently leading to an increase in the incidence of sports injuries. Understanding the epidemiological profile of foot and ankle's injuries in athletes is relevant for the prevention and treatment its occurrence. As far as we know, there is a lack of studies that report the epidemiological profile of athletes with foot and ankle disorders considering different sports. The aim of this study is to describe the epidemiology of foot and ankle injuries in athletes treated at an outpatient clinic specializing in injuries resulting from sports practice. The primary hypothesis is that ankle instability is the most frequent injury in athletes in the foot and ankle specialty outpatient clinic. Methods: Observational, retrospective, descriptive and comparative level IV of evidence study. The sample consisted of patients treated at an outpatient clinic specializing in foot and ankle injuries in sport, between January 1, 2015 and December 31, 2020. Three certified orthopedic physicians reviewed the charts and documented patient demographics, sport, diagnosis and lesion laterality. Age was analyzed according to age groups. The inclusion criteria were patients practicing amateurs or sports professionals of all age groups. We only count the first visits and the main modality and diagnosis of the patient. Exclusion criteria were insufficient data documented in chart, injuries that did not occur secondary to sports practice, and patients with conditions unrelated to the ankle and foot. Statistical analyzes were performed using software: SPSS V20, Minitab 16 and Excel Office 2010. We performed a multivariate logistic regression analysis to verify the association of gender, age and laterality with the main injuries documented. Results: A total of 763 patients (387 men and 376 women) met the inclusion criteria. The mean age was 35 years (SD= +-14.1; min=8.9; max=77). The most prevalent age group was young adults with 51.7% and the least prevalent was children with 1.4%. The most prevalent diseases were chronic lateral ankle instability (n=134, 17.6%), acute lateral ankle sprain (n=120, 15.7%) and plantar fasciitis (n=69, 9%). The multivariable analysis by logistic regression identified as a risk factor for lateral ankle instability the age group of young adults and females. In acute lateral ankle sprain, age was identified as a risk factor with statistical significance. In overuse injuries, only the female gender was evidenced as a risk factor. In non-insertional Achilles tendinopathy, bilaterality was associated as a risk factor with disease while in insertional Achilles tendinopathy, only the male gender was identified as a risk factor, as well as in Achilles tendon rupture. Conclusion: The literature specifically describing foot and ankle injuries during sport is limited, despite being highly prevalent injuries. Our work correlated several factors such as age, gender and laterality with specific sports through multivariate analysis, adding epidemiological data to the literature that help in the prevention and treatment of foot and ankle injuries in sports.
Category: Ankle Arthritis; Ankle; Other Introduction/Purpose: Decision regarding ankle osteoarthritis (OA) management varies depending on the severity and distribution of the associated joint degeneration. Disease staging is typically based on subjective grading of appearance on conventional plain radiographs, with reported sub-par reproducibility and reliability. Weight-bearing computed tomography (WBCT) offers clinical advantages in the setting of OA, where thinning of the ankle cartilage, softening of the cartilage, and other deformities become more apparent under load. WBCT also provides a better geometric representation of the ankle and allows for more accurate measurements when compared to a conventional radiograph. The purpose of this study was to develop and describe computational methods to objectively quantify radiographic changes associated with ankle OA apparent on low-dose WBCT images. Methods: We analyzed two patients with ankle OA and one healthy control that had all undergone WBCT of the foot and ankle. The severity of OA in the ankle of each patient was scored using the Kellgren-Lawrence (KL) classification by plain weight-bearing radiographs. For each ankle, the subsequent analysis focused on a volume of interest (VOI) centered on the tibiotalar joint. Within the VOI, the initial computational analysis focused on measuring the 3D joint space width (JSW). Subsequent analyses utilized WBCT image intensity (Hounsfield Unit, or HU) profiles along lines perpendicular to the subchondral bone/cartilage interface of the distal tibia extending across the entire VOI. The HU intensity profiles were recorded, and graphical plots of the HU distributions were generated for each line. These plots were then used to calculate the HU contrast, a novel measure of the regional variation in bone density. Results: The average JSW was 3.89 mm for the healthy control ankle, 2.69 mm for the mildly arthritic ankle (KL 2), and 1.57 mm for the severely arthritic ankle (KL 4). The average HU contrast was 72.31 for the healthy control ankle, 62.69 for the mildly arthritic ankle, and 33.98 for the severely arthritic ankle. The use of four projections at different locations throughout the joint allowed us to visualize specifically which quadrants have reduced joint space width and contrast. One projection in the severely arthritic ankle had JSW and contrast values of 0 due to complete joint space loss along with projection 4, which corresponds in this case to the posterolateral part of the joint (Figure). Conclusion: We presented a novel computational assessment of ankle osteoarthritis using low-dose WBCT imaging. We were able to demonstrate differences between normal ankles and ankles with mild and severe OA using JSW and HU contrast measurements. This methodology represents an important step towards a more reliable OA assessment when compared to the current standard qualitative evaluations, potentially serving as a starting point for the development of a more robust osteoarthritis staging system. Additional studies are needed to assess the algorithm more rigorously over a variety of radiographic presentations.
Category: Ankle; Ankle Arthritis; Hindfoot; Other Introduction/Purpose: Total ankle replacement (TAR) has been shown as a viable surgical option to reduce pain, improve function, and preserve ankle joint range of motion in patients with Ankle osteoarthritis (AO). Standard anterior approach TAR capability in correcting deformities is already established by several studies. However, there is a paucity of literature evaluating patient outcomes as well as the potential to correct alignment using a lateral approach TAR. Therefore, the primary objective of this study was to assess the capability of lateral trans-fibular approach TAR in correcting coronal and sagittal plane deformity and secondarily to report the ability to improve patient-reported outcomes (PROs) following lateral TAR. Methods: This IRB-approved, retrospective comparative study included 14 consecutive patients that underwent lateral trans- fibular approach TAR for end-stage AO. Average age and BMI were 63.9 years (range 43-83) and 32.7 kg/m2 (SD 7.5). All patients had received pre- and post-operative weight-bearing CT imaging on the affected foot and ankle. Foot and Ankle Offset (FAO), Talar Tilt Angle (TTA), Hindfoot Moment Arm (HMA), and Lateral Talar Station (LTS) were performed. PROs were collected pre- and post-operatively at the latest clinical follow-up including: PROMIS Global Physical Health score, the Tampa Scale of Kinesiophobia (TSK), the European Foot and Ankle Society (EFAS) score, the Pain Catastrophizing Scale (PCS) and the Foot and Ankle Ability Measure (FAAM) Daily Living Score. One-way ANOVA and Wilcoxon tests were used for comparison at each interval time period. A multivariate regression analysis was then performed to evaluate the association between change in alignment and improvements of PROs. Results: Three of 14 patients (21.4%) underwent a concomitant osseous re-alignment procedure. At an average of 16.1 months (range 11 to 24), all patients demonstrated a significant deformity correction in measurements performed: FAO (7.73% - 3.63%, p=0.031), HMA (10.93mm - 5.10mm, p=0.037), TTA (7.9o - 1.5o, p=0.003), and LTS (5.25mm - 2.83mm, p=0.018). Four of the PROs demonstrated significant improvement postoperatively: TSK (42.7-34.5, p=0.012), PROMIS Global Physical Health (46.1- 54.5, p=0.011), EFAS (5-10.3, p=0.004), and FAAM (60.5-79.7, p=0.04). PROMIS was associated (p=0.0015) with optimization of FAO (p=0.00065) and LTS (p=0.00436), R2 of 0.98). Improvements in TSK were associated with changes in the HMA (p=0.0074), R2 of 0.66. Improvements in FAAM correlated (p=0.048) with improvements in FAO (p=0.023) and TTA (p=0.029), and an R2 of 0.78. Conclusion: In this retrospective comparative cohort study, the results suggest that the lateral trans-fibular TAR can correct different aspects of AO deformity. Clinical benefit was also demonstrated by the impacted PROs, particularly TSK, PROMIS Global Physical Health, EFAS, and FAAM Daily Living. Direct and strong correlations between deformity correction measurements and the significantly improved PROs were found. The obtained data might help surgeons when planning treatment and may serve as the basis for future comparative prospective studies.
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