An estimated 40% of the US population have foot problems.Of all patients aged over 50 years, 2.5% report degenerative arthritis of the first metatarsophalangeal (MTP) joint, termed 'hallux rigidus'. ...First MTP osteoarthritis is the most common arthritic condition in the foot.Progression of great toe arthritis is associated with pain and loss of motion. Non-surgical intervention begins with shoe modifications and orthotics designed to limit MTP motion.In patients with mild arthritis, operative procedures focus on removing excess osteophytes (cheilectomy) to prevent dorsal impingement with or without a concomitant osteotomy (Moberg) to improve or shift range of motion into a less painful arc.In patients with more advanced arthritis, operative management has centred on arthrodesis of the first MTP joint.A recent Level 1 study shows excellent function and pain relief with a small hydrogel hemi-implant into the metatarsal headMultiple joint-sparing procedures such as joint arthroplasty or resurfacing have been described with inconsistent results. Cite this article: EFORT Open Rev 2017;2:13-20. DOI: 10.1302/2058-5241.2.160031.
Acute rupture of the Achilles tendon is common and seen most frequently in people who participate in recreational athletics into their thirties and forties. Although goals of treatment have not ...changed in the past 15 years, recent studies of nonsurgical management, specifically functional bracing with early range of motion, demonstrate rerupture rates similar to those of tendon repair and result in fewer wound and soft-tissue complications. Satisfactory outcomes may be obtained with nonsurgical or surgical treatment. Newer surgical techniques, including limited open and percutaneous repair, show rerupture rates similar to those of open repair but lower overall complication rates. Early research demonstrates no improvement in functional outcomes or tendon properties with the use of platelet-rich plasma, but promising results with the use of bone marrow-derived stem cells have been seen in animal models. Further investigation is necessary to warrant routine use of biologic adjuncts in the management of acute Achilles tendon ruptures.
Background Previous studies have shown no correlation between adhesive capsulitis and hemoglobin A1c (HbA1c ). However, HbA1c is only a measure of short-term blood sugar control. We created a ...previously nonvalidated variable, cumulative HbA1c , that uses HbA1c values over time to estimate the total disease burden a single individual experiences over a period. In this study, we aimed to evaluate whether a correlation exists between cumulative HbA1c levels in diabetic patients and the prevalence of frozen shoulder. We hypothesized that poor long-term glucose control would be correlated with increased incidence of adhesive capsulitis. Methods A retrospective analysis at a single institution was performed. Data from all patients from a single institution with any HbA1c values were collected. A total of 24,417 patients met the inclusion criteria. A variable was created establishing the cumulative magnitude of abnormal HbA1c values over time, termed “cumulative HbA1c .” Logistic regression analysis was performed to determine whether long-term glucose control was predictive of the development of adhesive capsulitis. Results Cumulative HbA1c was positively associated with adhesive capsulitis (7.6 × 10–5 ) (ie, odds ratio of 1.000076). The effect size of cumulative HbA1c on adhesive capsulitis was significant; for each unit of time that the HbA1c level was greater than 7, there was a 2.77% increase in the risk of adhesive capsulitis. Discussion Cumulative HbA1c was associated with an increased incidence of adhesive capsulitis. This finding suggests that the effects of diabetes that predispose patients to the development of adhesive capsulitis are dose dependent. Patients with worse blood sugar control over a longer period are at an increased risk of the development of adhesive capsulitis.
Background:
Following open reduction internal fixation (ORIF) of unstable ankle fractures, some patients have persistent pain and poor outcomes. This may be secondary to intra-articular injuries that ...occur at the time of fracture, which occur in up to 88% of fractures. Ankle arthroscopy at the time of ORIF has been proposed to address these intra-articular injuries. This study compared patient-reported functional outcomes in patients who underwent ankle ORIF with and without ankle arthroscopy.
Methods:
An institutional database was used to retrospectively identify 93 patients who underwent ORIF for an unstable ankle fracture with an intact medial malleolus between 2002 and 2013. Forty-two patients had ankle arthroscopy at the time of ORIF and 51 did not. Functional outcomes between groups were compared using Patient Reported Outcomes Measurement Information System (PROMIS) physical function and pain interference computerized adaptive tests at a minimum follow-up of 1 year. Outcomes were also measured with the visual analog scale (VAS) pain score and the Olerud and Molander ankle fracture outcome scale. Average patient follow-up was 67 months (n = 51).
Results:
PROMIS physical function and pain interference scores were not significantly different between groups (physical function, 57.8 vs 54.5, P = .23; pain interference, 45.6 vs 46.9, P = .56). Operative time was increased in the arthroscopy group (74 minutes vs 59 minutes, P = .027). Overall, 60% (25/42) had chondral lesions of the talus, 7% (3/42) had chondral lesions of the tibial plafond, and 21% (9/42) had loose bodies requiring removal. There was no significant difference in complication rates between groups.
Conclusion:
At intermediate-term follow-up of patients with unstable ankle fractures and intact medial malleoli, functional outcomes were not significantly improved in patients who underwent ankle arthroscopy. However, there were no increased complications attributable to ankle arthroscopy, and average total operative time was increased by only 15 minutes.
Level of Evidence:
Level III, retrospective cohort study.
Arthritis of the first metatarsophalangeal (MTP) joint, hallux rigid, is a common and disabling source of foot pain in the adult population. Hallux rigidus is characterized by diseased cartilage and ...large, periarticular osteophytes that result in a stiff, painful joint. Activity modification, sensible shoes, orthotics, anti-inflammatory medications and occasional intra-articular steroid injections can be attempted to alleviate the discomfort associated with hallux rigidus. A number of surgical options exist for the treatment of recalcitrant hallux rigidus. Cheilectomy is a useful treatment for dorsal impingement pain seen in mild hallux rigidus. A new polyvinyl alcohol hemi-arthroplasty implant has shown promising early and midterm results in the treatment of advanced hallux rigidus; however, arthrodesis of the first MTP joint remains the gold standard treatment for advanced hallux rigidus because of unpredictable outcomes after early-generation joint replacement implants.
Background:
The overall health and the importance of physical therapy for people following total ankle arthroplasty (TAA) have been understudied. Our purpose was to characterize the overall health of ...patients following TAA, and explore the frequency, influence, and patient-perceived value of physical therapy.
Methods:
People who received a TAA participated in this retrospective cohort online survey study. The survey included medical history questions and items from the Patient-Reported Outcomes Measurement Information System (PROMIS) Short Forms. Seven PROMIS domains, reflecting the biopsychosocial model of care (physical, mental, social), were included to examine participant overall health status in comparison to the general population. Items regarding physical therapy participation (yes/no), number of visits, and perceived value (scale 0-10; 10 = extremely helpful) were also included. Descriptive statistics were generated for participant characteristics, PROMIS domain T scores, and physical therapy questions. The influence of participant characteristics or physical therapy visits on PROMIS domain T scores that scored below the population mean were examined with multiple linear regression or ordinal regression.
Results:
The response rate was 61% (n=95). Average postoperative time was approximately 3 years (mean SD: 40.0 35.3 months). Physical function and ability to participate in social roles and activities domain T scores were at least 1 SD below the population mean. Most patients received physical therapy (86%; 17.1 11.0 visits) and found it helpful (7.2 3.0). Participant characteristics were minimally predictive of physical function and social participation T scores. Number of physical therapy visits predicted physical function T scores (P = .03).
Conclusions:
Most health domain scores approached the population mean. Physical therapy was perceived to have a high value, and greater visits were related to greater physical function. However, lower physical function and social participation scores suggest that postoperative care directed toward these domains could improve the value of TAA and promote overall health.
Level of Evidence:
Level III, retrospective comparative study.
Staged primary ankle arthrodesis is a viable option for high-energy pilon fractures that are nonreconstructible, in patients with delay in treatment or multiple medical comorbidities, or in patients ...with peripheral neuropathy. Small retrospective series demonstrate high union and low wound complication rates, although further studies are needed to determine the long-term results. Ankle arthrodesis offers decreased complication rates while eliminating the potential of posttraumatic ankle arthritis pain.
Glycemic control is a known modifiable risk factor for diabetic foot disease. Prior attempts to define its relationship with diabetic foot ulcer and Charcot arthropathy fail to account for ...variability in control and duration of diabetic disease. We developed a novel metric to reflect aggregate disease exposure in a diabetic, termed cumulative glycemic burden. We hypothesized that it would be positively associated with both diabetic foot ulcer and radiographically diagnosed Charcot arthropathy.
Patients aged 18 to 90 years with ≥3 hemoglobin A1c (HbA1c) values were identified retrospectively at a single institution over a 15-year period. Primary outcomes were ICD-9 diagnosis of foot ulcer and radiographically diagnosed Charcot arthropathy. Cumulative glycemic burden was calculated by trapezoidal integration of the area under a curve defined by HbA1c values above 7 over time. Patients were stratified into quartiles based on cumulative glycemic burden (excellent, good, fair, and poor control). χ
tests compared the proportion of foot ulcer and Charcot across quartiles. Regression analysis identified associated demographic and comorbidity factors with diabetic foot disease. Statistical significance was set at P < .05.
Out of 22,913 diabetics, 1643 (7.2%) had a foot ulcer; 54 out of 771 diabetics (7.0%) had radiographic Charcot arthropathy. There was a statistically significant stepwise increase in the incidence of foot ulcer with increasing cumulative glycemic burden by patient quartile (5.2 vs. 6.4 vs. 7.9 vs. 13.9%; P < .001). No significant trend was seen between incidence of Charcot arthropathy and greater cumulative glycemic burden (7.8 vs. 5.6 vs. 4.4 vs. 10.0%; P = .469). Peripheral vascular disease was most strongly associated with diabetic foot ulcer. Hypertension and diabetic neuropathy were independently associated with Charcot arthropathy.
Increasing cumulative glycemic burden is positively associated with diabetic foot ulcer. Greater attention should be paid towards the most poorly controlled diabetics with the longest duration of disease to reduce their risk. Cumulative glycemic burden is not associated with Charcot arthropathy.
Previous studies have shown no correlation between adhesive capsulitis and hemoglobin A
(HbA
). However, HbA
is only a measure of short-term blood sugar control. We created a previously nonvalidated ...variable, cumulative HbA
, that uses HbA
values over time to estimate the total disease burden a single individual experiences over a period. In this study, we aimed to evaluate whether a correlation exists between cumulative HbA
levels in diabetic patients and the prevalence of frozen shoulder. We hypothesized that poor long-term glucose control would be correlated with increased incidence of adhesive capsulitis.
A retrospective analysis at a single institution was performed. Data from all patients from a single institution with any HbA
values were collected. A total of 24,417 patients met the inclusion criteria. A variable was created establishing the cumulative magnitude of abnormal HbA
values over time, termed "cumulative HbA
." Logistic regression analysis was performed to determine whether long-term glucose control was predictive of the development of adhesive capsulitis.
Cumulative HbA
was positively associated with adhesive capsulitis (7.6 × 10
) (ie, odds ratio of 1.000076). The effect size of cumulative HbA
on adhesive capsulitis was significant; for each unit of time that the HbA
level was greater than 7, there was a 2.77% increase in the risk of adhesive capsulitis.
Cumulative HbA
was associated with an increased incidence of adhesive capsulitis. This finding suggests that the effects of diabetes that predispose patients to the development of adhesive capsulitis are dose dependent. Patients with worse blood sugar control over a longer period are at an increased risk of the development of adhesive capsulitis.
Abstract Background and purpose Tibial shaft fractures are often treated by intramedullary nailing (IMN) or plate fixation. Our purpose was to compare the 30-day complication rates between IMN and ...plate fixation of extra-articular tibial fractures. Materials and methods We conducted a retrospective analysis of prospectively collected patient demographics, comorbidities, and 30 day complications of isolated closed extra-articular tibial shaft fractures from 2006 to 2012 using the American College of Surgeon's National Surgical Quality Improvement Program (ACS-NSQIP) database. A 1:2 propensity-matched dataset was created to control for differences in preoperative demographics and comorbidities across the plate fixation and IMN groups. Univariate and multivariate analyses were used to assess differences in complications between the groups and the independent effects of plate fixation or IMN on complications. Results A total of 771 patients were identified with 234 (30.4%) in the plate fixation and 537 (69.6%) in the IMN group. We found no statistical difference in rates of wound complications, medical complications, reoperation, or mortality in our propensity matched analyses. Plate fixation was found to be independently associated with a lower risk of postoperative blood transfusion compared to IMN (odds ratio 0.326, p = 0.032). Plate fixation was not independently associated with any other examined complications. Conclusions We found no difference in 30-day postoperative complications between plate fixation and intramedullary nailing of isolated extra-articular tibia fractures with the exception of decreased postoperative transfusion requirements with plate fixation. We conclude that both procedures offer a similar short-term complication profile.
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