Consumer Prices for Surgical Management of Ankle Arthritis: Limited Availability and Wide Variability.

Background: Healthcare costs for the surgical management of ankle arthritis continue to rise. Patients are generally unaware of the prices of the services they use. Understanding the costs associated with surgical management of ankle arthritis is an important facet of patient care. The purposes of this study were to (1) determine the access to the surgical cost of total ankle arthroplasty (TAAs) and ankle arthrodesis and (2) the variability of the price between the two procedures. Methods: Fifty foot and ankle centers (25 academic, 25 private) that perform TAAs and ankle arthrodeses were contacted using a standardized patient script. The described patient was a 63-year-old man who had failed conservative treatment of ankle arthritis. Each institution was contacted up to three times in an attempt to obtain a full-bundled surgical quote for a TAA and an ankle arthrodesis. Results: Twenty-one centers (42%, 14 academic, 7 private) were able to provide a quote for a TAA and an ankle arthrodesis. The mean bundled price for a TAA was $50,332 (SD ±$25,744), with the mean academic and private center quote being $56,529 and$37,937, respectively. The mean bundled price for an ankle arthrodesis was $41,756 (SD ±$26,033), with the mean academic and private center quote being $48,116 and$29,037, respectively. No statistically significant difference was found between the bundled prices for TAA and ankle arthrodesis. Discussion: This study demonstrated limited availability of consumer prices for TAA and ankle arthrodesis. When comparing different institutions for surgical management of ankle arthritis, there was a wide range of quotes for both TAA and ankle arthrodesis. When comparing the choice of surgical management for ankle arthritis, no statistically significant difference was observed in price between TAA and ankle arthrodesis

Introduction: Why Are There so Many Different Surgeries for Hallux Valgus?

Hallux valgus is a common pathology of the foot and ankle. Surgical correction of the condition has been described as early as 1836. Since then, numerous different surgical techniques have been documented in the literature. One of the explanations as to why there are so many different surgeries for hallux valgus is the variety of etiologies attributed to causing the condition. This article discusses the etiologies associated with hallux valgus and describes a few of the surgeries commonly used to treat the deformity

A Decade of Social Media Influence on Foot and Ankle Literature

Category: Ankle; Ankle Arthritis; Arthroscopy; Basic Sciences/Biologics; Bunion; Diabetes; Hindfoot; Lesser Toes; Midfoot/Forefoot; Sports; Trauma; Other Introduction/Purpose: The topics, articles and discussions that arise within Foot and Ankle Orthopaedic literature are increasingly determined by their presence on social media outlets. The influence of social media mentions on Foot and Ankle Orthopaedic literature has not yet been investigated. The primary purpose of this study is to identify the social media outlets that were most associated with the Altmetric attention score (AAS). The secondary aim is to characterize the top 100 most highly cited articles within Foot and Ankle literature with the top 100 scoring Altmetric articles. Methods: We conducted a query of the Altmetric database for all journal titles containing the words ‘Foot’ and ‘Ankle.’ In accordance with other investigations, articles were only included after 2010, since this was beginning of academic social media participation. We assessed the frequency and percent of articles by journal, collecting variables including impact factor, AAS, along with average mentions within news, blogs, policy, patents, Twitter, peer review, Weibo, Facebook, Wikipedia, Google+, LinkedIn, Reddit, Pinterest, F1000, Q&A, online video, Syllabi, and traditional metrics such as number of Mendeley readers and citations (Table 1). We used a Spearman, semi-partial, and partial correlation test to detect the association between AAS and media outlet mentions, Mendeley readers or Dimensions citations. Finally, we ranked one article list with the 100 most popular articles on social media and one with the 100 most cited articles. Articles were examined for overlap, topic, article type, and level of evidence. Results: Our search returned 4,365 articles. Foot and Ankle International had the highest frequency of articles, though the Journal of Foot and Ankle Research had the highest AAS (Table 1). News and Twitter mentions had the greatest association with AAS. The top study designs for the AAS articles were prospective (n=35), retrospective (n=25), and systematic reviews (n=17), compared to the most highly cited articles which had retrospective (n=32), review (n=31), and observational studies (n=26) (p<0.001). When examining the top 100 highest AAS scoring articles with the 100 most cited, there was only one article in both groups. Compared to the most highly cited articles, the highest ranked AAS articles had a better average level of evidence (Cited: 3.4 vs. AAS: 2.9, p=0.001). Conclusion: Twitter and mentions within news are the most correlated with AAS. Although traditional metrics for article influence often reference an article’s citation count, attaining social media relevance is becoming more important than before. There is currently very little overlap among the most highly cited and the most mentioned articles on social media. Future research is needed to address whether citation counts or social media presence have more influence on actual clinical practice

Hallux Valgus Correction: Comparison of Minimally Invasive Transverse and Chevron Distal Metatarsal Osteotomy Constructs

Category: Basic Sciences/Biologics; Bunion Introduction/Purpose: Hallux valgus is one of the most common surgically corrected forefoot deformities. Compared to open procedures, minimally invasive treatment of hallux valgus has resulted in decreased operative time, reduced complication rates, and greater patient satisfaction. Until recently in the United States, distal chevron osteotomies have been the standard for hallux valgus correction of moderate deformity. To the best of the authors’ knowledge, no studies have evaluated biomechanical strength of transverse and chevron distal metatarsal osteotomy constructs. The purpose of this study was to evaluate the biomechanical strength of transverse and chevron minimally invasive osteotomy techniques using 9 matched cadaveric pairs. Methods: A total of nine matched cadaveric specimens were randomized to transverse or chevron distal metatarsal osteotomies. Each minimally invasive surgical technique was performed by a fellowship trained orthopedic foot and ankle surgeon. Anterior- posterior and lateral radiographic images were obtained following surgical fixation. Biomechanical testing was performed on an Instron Mechanical System. Ultimate load to failure, yield load, and stiffness were assessed across the fixation construct with fulcrum within the metatarsal shaft proximal to screw fixation and compression load at the sesamoid bones. A pre-load of 10N was applied to the sesamoid bones by the compression post to stabilize the sample. Subsequently, a compression rate was applied to the sample at 10mm/min until failure was observed. Mean and standard deviations were assessed and compared across cohorts. Results: All nine cadaveric specimens were male. There was no difference in average percent metadiaphyseal shift among transverse (36%) and chevron (38%) osteotomies. The most common mode of failure among transverse and chevron osteotomies was fracture at screw insertion site (55.6%), followed by failure at osteotomy site (44.4%). One paired sample was noted to have poor bone quality prior to biomechanical testing. There was a trend towards increased ultimate load to failure (p=0.480) and stiffness (p=0.438) among transverse osteotomy compared to chevron osteotomy, however, no statistically significant difference was observed. Conclusion: Biomechanical testing demonstrates no statistical difference in ultimate load to failure and stiffness between minimally invasive transverse and chevron distal metatarsal osteotomy constructs. A trend towards increased ultimate load and stiffness in the transverse osteotomy cohort was observed. Chevron osteotomies violate the entire plantar cortex and may result in early failure by relative ease of cutout through cancellous bone compared to transverse osteotomies in which failure would require cortical bone cutout. Future studies are required to evaluate strength of construct in a larger sample. Analysis is limited, healing may provide additional strength that is not simulated in cadaveric studies

Evaluating Outcomes After Midfoot Bone Block Arthrodesis

Category: Midfoot/Forefoot Introduction/Purpose: Midfoot arthrodesis requires a structural graft where bone loss from AVN, osteomyelitis and erosive arthritis is present in the navicular, cuneiform or 1st metatarsal. The goal of this study was to evaluate radiographic outcomes of midfoot bone block arthrodesis. Methods: A retrospective, IRB approved study was completed evaluating midfoot arthrodesis between 2002 and 2014. where structural bone graft was used as part of an arthrodesis of the tarsometatarsal (TMT) joints or the naviculocuneiform (NC) joints or both. Demographic characteristics were obtained including age, body mass index (BMI), diagnosis, diabetes or tobacco use, indication for use of bone block, location of the bone block, and type of graft used. Radiographic data collected included time to union, the number of patients in which union was obtained, and graft length Results: Over a 12-year period, there were a total of 33 with an average age of 57.9 years, and included 20 females and 13 males with an average BMI of 29. The average length of follow up was 24 months. The most common diagnoses was erosive midfoot arthritis (11) and prior navicular fracture associated with AVN (9). Structural allograft was used in all patients. (first TMT (10), talocuneiform (9), other combinations (14)). Various types of biologic agents were used in 20 of 33 arthrodeses. Radiographic evidence of union was found in 21/33 patients (63.6%) at an average of 4.7 months after surgery. Twelve patients developed a nonunion. The risk factors for nonunion include age > 50, the presence of erosive osteoarthritis, AVN of the navicular and lack of use of biologic stimulation. There was no correlation between the presence of diabetes, a prior history of infection or prior history of trauma and development of nonunion. Conclusion: The radiographic fusion rate of patients undergoing large structural midfoot bone graft arthrodesis was 63.6% with radiographic evidence of healing present in this group at 4.77 months after surgery. This is the first known study reporting on radiographic outcomes of structural bone graft arthrodesis of the midfoot. The rate of fusion seen here is slightly better compared with recent studies evaluating healing of large defects using femoral head structural allografts. Nonetheless, the risk of non-union remains far greater than when an in situ arthrodesis of these same joints are performed

Peroneal Tendinosis and Subluxation

Peroneal tendinosis and subluxation are lifestyle-limiting conditions that can worsen if not properly diagnosed and treated. Adequate knowledge of ankle anatomy and detailed history and comprehensive physical examination is essential for diagnosis. Peroneal tendinopathy is likely to result from overuse, whereas subluxation often precipitates from forceful contraction of peroneals during sudden dorsiflexion while landing or abruptly stopping. In athletes, conservative measures remain first-line treatment of tendinopathy, but surgery is often immediately indicated in cases of recurrent symptomatic subluxation or dislocation. Surgical technique varies on the type, mechanism, and severity of injury, but most procedures have a high success rate

The Biomechanical Evaluation of Revision First Metatarsophalangeal Arthrodesis: A Cadaveric Study

First metatarsophalangeal (MP) arthrodesis in the setting of bone loss is a difficult problem. Bone loss may compromise stability of implant fixation. Union rates may be adversely affected by these circumstances. The primary goals of this cadaveric, biomechanical study were to (1) investigate stiffness of a dual mini-plate construct versus a standard MP arthrodesis plate in the setting of severe bone loss and (2) evaluate arthrodesis interface motion when an interpositional graft is used. Twelve matched cadaveric samples were used in this study. In a given pair, both dual mini-plate fixation and standard MP arthrodesis plate were used. Interpositional graft was used in 6 of the specimen pairs. After implantation, soft tissues were dissected away and specimens were placed into a cantilever bending setup. A cantilever load was applied at a rate of 6 mm/min until catastrophic failure of the test construct or 5-mm plantar gapping of either bone block interface. Based on load to failure data, there were no differences between the various constructs in terms of stiffness. There was a high degree of calculated plantar gapping with the placement of a bone block, irrespective of the fixation type. Although no construct differences were observed in terms of stiffness, the dual mini-plate is an alternative option for fixation when asymmetric bone loss is either seen on the phalangeal or metatarsal head side. The high degree of plantar gapping of the proximal interface with the placement of the bone block may have implications for healing potential across the arthrodesis site. This is the first biomechanical study investigating the stiffness of multiple constructs for MP arthrodesis in the setting of severe bone loss. Furthermore, this is the first study to introduce a biomechanical rationale for difficulties in healing for this particular clinical scenario. Level V: Bench testing

Regional Genetic Responses of Porcine Talar Articular Cartilage to Impact Injury

Category: Ankle Arthritis Introduction/Purpose: The ankle is at greatest risk for post-traumatic osteoarthritis (PTOA) in comparison to the hip or knee. Adaptive changes to the cartilaginous topography may be a marker for where cartilage damage poses the greatest risk of development of osteoarthritis. The objective of this study was to elucidate the mechanism of PTOA by analyzing the changes in regional genetic expression of inflammatory markers after impact injury in an ex-vivo porcine model. Methods: Talus bones were recovered from 5 porcine ankles. A drop tower was used to induce injury by dropping a 1000 g weight from a height of 15 cm on the talus. Following the injury the bone was cultured for 24 hours. Four 6-mm cartilage plugs were harvested from the inferior aspect of each talus bone and a small slice of each plug was used for cell imaging. The remaining cartilage plugs were flash frozen with liquid nitrogen and stored at -80°C for ribonucleic acid (RNA) extraction and analysis of gene expression. Expression of inflammatory and catabolic genes (IL1-ß, TNF-a, ADAMTS-5, ADAMTS-4, MMP-3 and MMP-13) was compared among the samples obtained from the non-impacted and impacted sites of the anterior and posterior regions. Student t-test was performed to examine the differences between the control (non-impact) and impacted samples from each region and between the control samples from the anterior and posterior regions. Results: The current porcine impact model demonstrated significant up-regulation of several inflammatory cytokines and metalloproteinases by impact force. Among the genes tested, TNF-a, ADAMTS-4, and MMP-3 showed increased expression at impact sites (p<0.05) compared to non-impact sites in the posterior region (Figure 1) whereas no differences were found in the anterior region. Interestingly, the non-impacted samples in the anterior region exhibited significantly higher expression of TNF-a, ADAMTS-4, MMP-3 and ADAMTS-5 than those of the posterior region (p<0.05). Conclusion: The results of the current ex-vivo porcine impact study demonstrate significant up-regulation of inflammatory and catabolic genes 24 hours after porcine talus bone impaction. These findings highlight the relevance of regional differences in post- traumatic ankle inflammation; the posterior region of porcine talar articular cartilage demonstrated increased sensitivity in response to injury. The anterior region illustrated greater resistance to injury, showing less gene up-regulation compared to the posterior region of the same ankle. These findings suggest that location of cartilage injury may play a crucial role in the development of inflammatory response, chondrocyte apoptosis, and subsequent osteoarthritis of the ankle

Prevalence of Metatarsus Adductus in Patients Undergoing Hallux Valgus Surgery

Metatarsus adductus (MA) is a congenital condition in which there is adduction of the metatarsals in conjunction with supination of the hindfoot through the subtalar joint. It is generally believed that MA precedes the development of hallux valgus. Historically, studies have demonstrated that patients with a history of MA were ~3.5 times more likely to develop hallux valgus. The purpose of this study was to identify the relative prevalence of MA in patients undergoing surgery for symptomatic hallux valgus. Between 2002 and 2012, 587 patients who underwent hallux valgus surgery were retrospectively identified following IRB approval and parameters including the hallux valgus angle (HVA), the intermetatarsal angle (IMA), and the metatarsus adductus angle (MAA) were recorded. The MAA was considered abnormal if the value was greater than 20 degrees. Interobserver and intraobserver reliability studies for the measurement of the MAA were completed as well. Using the modified Sgarlato technique for measurement of the MAA, there was a high interobserver and intraobserver reliability. The interclass and intraclass coefficients were greater than .90. The prevalence of MA in this patient population was found to be 29.5%. Of those patients with MA, 23 males and 150 females were identified. This gave a male to female ratio of 1:6.5 (P < .00001). Lesser toe deformities (claw toes, hammertoes) were the most commonly associated diagnoses identified. When stratified by severity, 113 (65%) patients had an MAA between 21 and 25 degrees, 41 (23.7%) had an MAA between 26 and 30 degrees, 8 (4.6%) patients had an MAA between 31 and 35 degrees, and 11 (6.3%) patients had an MAA greater than 36 degrees. Historically the prevalence of MA in patients with hallux valgus has been reported to be 35%. The data in this study indicate a comparable prevalence at 29.4%. The presence of concomitant MA may portend different outcomes for operative treatment of hallux valgus. Further research needs to delineate rates of persistence of deformity in this patient population to guide operative management. Level IV, case series

Management of Isolated Lateral Malleolus Fractures

Isolated lateral malleolus fractures represent one of the most common injuries encountered by orthopaedic surgeons. Nevertheless, appropriate diagnosis and management of these injuries are not clearly understood. Ankle stability is maintained by ligamentous and bony anatomy. The deep deltoid ligament is considered the primary stabilizer of the ankle. In the setting of an isolated lateral malleolus fracture, identifying injury to this ligament and associated ankle instability influences management. The most effective methods for assessing tibiotalar instability include stress and weight-bearing radiographs. Clinical examination findings are important but less reliable. Advanced imaging may not be accurate for guiding management. If the ankle is stable, nonsurgical management produces excellent outcomes. In the case that clinical/radiographic findings are indicative of ankle instability, surgical fixation options include lateral or posterolateral plating or intramedullary fixation. Locking plates and small or minifragment fixation are important adjuncts for the surgeon to consider based on individual patient needs