A novel flexible fixation technique for Lisfranc injuries: clinical outcomes and radiographic follow-up

Objectives: The purpose of this investigation is to present the follow-up results and patient-reported outcome measures (PROMs) of a continuous series of surgically managed Lisfranc injuries whose constructs included a novel technique. Methods: Our billing database was retrospectively queried by Current Procedural Terminology (CPT) codes to identify all Lisfranc injuries managed operatively between 2018 and 2021. Basic demographic data were collected. Clinical notes and radiographs were reviewed. Patients were contacted prospectively to complete the Foot and Ankle Ability Measurement – Activities of Daily Living (FAAM-ADL), Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Intensity, PROMIS Pain Interference, and PROMIS Depression surveys. Descriptive statistics were calculated. Results: Sixteen patients were included. While all patients underwent flexible fixation (FF), nine of them underwent concomitant open reduction internal fixation (ORIF) and seven, concomitant primary arthrodesis. Median radiographic and PROMs follow-up time was 7.3 months (IQR 4.4–11.6) and 25.8 (IQR 9.5–32.4), respectively. All fusion patients had evidence of joint fusion, and 8/9 of ORIF patients maintained articular congruity without evidence of arthritis at final follow-up. Median PROMs were 85 (64.75–93.5), 53.1 (49.7–57.75), 45.7 (37.7–51.3), and 46 (43.3–52.28) for the FAAM-ADL, PROMIS Pain Interference, PROMIS Pain Intensity, and PROMIS Depression scores, respectively. Conclusion: The novel FF technique proposed for residual tarsometatarsal subluxation in Lisfranc injuries appears to be safe and effective, with good PROMs at two-year follow-up and low complication rates, obviating the need for hardware removal. Level of Evidence IV; Therapeutics Studies; Cases Series

Risk of congenital heart disease in relatives of probands with conotruncal cardiac defects: An evaluation of 1,620 families

Current recurrence risk counseling for conotruncal cardiac defects (CTD) is based on empiric estimates from multiple studies. We examined the risk of congenital heart disease (CHD) in relatives of probands with CTDs to assist in counseling practices in the current era. One thousand six-twenty probands with CTDs and no reported chromosomal or genetic abnormalities were recruited sequentially. A three-generation pedigree was obtained for each proband by a genetic counselor detailing the presence and type of CHD in each family member. Risks and 95% confidence intervals (CI) were calculated for sub-groups of relatives based on degree of relationship for all probands and by individual lesion of the proband. For pairs of affected relatives, concordance rates were calculated. Severity of CHD in the affected relative was assessed. The risk of CHD was higher in siblings (4.4%, 95% CI 3.4-5.4) than in parents (1.5%, 95% CI 1.1-1.9). Risk varied by the cardiac lesion of the proband with the highest risk in first-degree relatives of probands with tetralogy of Fallot and the lowest in D-transposition of the great arteries. 39% of affected parents and 69% of affected siblings had a concordant lesion (i.e., CTD). Most affected siblings of probands with severe CTDs had complex defects (58%), whereas very few affected parents had complex defects (20%). These data suggest that recurrence risk varies by lesion and relationship, with substantial concordance observed by cardiac lesion and complexity of disease, particularly among siblings. These findings contribute to risk counseling in the current era

The Lateral Fibular Stress Test: High Variability of Force Applied by Orthopaedic Surgeons in a Biomechanical Model

Background: The lateral fibular stress test (LFST), also known as the hook or Cotton test, is commonly performed to assess syndesmotic instability intraoperatively. Several studies have used 100 N as the force applied when performing the LFST to detect syndesmotic instability, though no evidence-based requisite force has been described for the test. We hypothesize that surgeons do not apply force uniformly or consistently when performing the LFST and that substantial variation exists. Fundamentally, this could lead to inconsistent diagnosis of syndesmotic instability as surgeons may not be applying the force in a consistent manner. Methods: A biomechanical ankle model consisting of an industrial force gauge attached through a SawBones model was fashioned. Orthopaedic attending surgeons and trainees were asked to perform a series of LFSTs and to simulate the force they typically apply intraoperatively. Basic demographic data were collected on each participant. Results: Thirty-three surgeons participated in the study, including 18 trainees. The median (IQR) force applied during the LFST was 96.42 (71.42-126.33), 87.49 (69.19-117.40), 99.99 (79.91-137.49), for the pooled group, attendings, and trainees respectively. More than half (54.5%) of all trials were less than 100 N (57.8% of surgeons, 51.8% trainees). Intraobserver correlation was excellent within the overall cohort (0.92, P < .001), trainees (0.90, P < .001), and attendings (0.94, P < .001), respectively. Interobserver reliability was fair among the overall cohort (κ =0.28, P = .49), and poor between the attendings (κ = 0.11, P = .69) and the trainees (κ = 0.05, P = .82), respectively. Conclusion: Our study demonstrates that the amount of force applied by typical surgeons when performing the LFST test is highly variable. Variable force application when performing the LFST may lead to inconsistent detection of syndesmotic instability, which may portend a poorer outcome. Clinical Relevance: In this study, we demonstrate the wide variability in the amount of force used during a lateral fibular stress test. High variability of force application when performing the LFST may lead to inconsistent diagnosis of syndesmotic instability, which may portend a poorer outcome. Our findings suggest the need for further investigation into the technical aspects of syndesmotic testing that will permit more reproducible and valid interrogation of the syndesmosis

Clinical Comparison of Internal Fixation Constructs in Midfoot Charcot Arthropathy

Category: Diabetes; Midfoot/Forefoot Introduction/Purpose: Midfoot Charcot can lead to instability, deformity and ultimately ulceration that can be limb threatening. Previous authors have described a variety of surgical stabilization techniques and constructs including intramedullary fixation (“beaming”) across the midfoot in varying orientations. More recently, intramedullary compression nails (“IM nail”) have been introduced. In contrast with static screws, these devices provide compression across the joints of the midfoot by engaging a compression mechanism against a fixed interlock screw. To our knowledge no clinical comparison between traditional beaming techniques and modern compression nails for midfoot Charcot has been reported. We hypothesize that using IM nails will result in a higher union rate, and lower reoperation and hardware failure rates. Methods: Our electronic medical record was queried to identify patients from 2016-2021 who underwent midfoot reconstruction. Only patients with midfoot Charcot who underwent extended intramedullary fixation were included. Patients with active ulceration at the time of surgery, Charcot that included the ankle, or external fixation as part of the construct were excluded. IM nails were used exclusively for medial column constructs. Basic demographic information was collected. Radiographs and operative notes were evaluated and construct type and implants used were noted. Radiographs at final follow-up were evaluated for union and hardware complication. Clinical notes were evaluated for weightbearing status, plantigrade foot position, ulceration, and wound care requirements. Finally, all complications and reoperations were recorded. Chi-squared or Fisher’s Exact tests were used as appropriate to compare categorical variables and t-tests were used to compare numerical variables. Results: 48 feet (47 patients) with a median age of 58 years (IQR 50, 64) were included. Diabetes was the Charcot etiology in 34/48 (70.8%) feet. There were 19 beaming and 29 IM nail constructs. Basic demographics and Brodsky classification were equally distributed (p>0.05). Median follow-up time was 1.3 years (IQR 0.8, 2.9). Combined medial and lateral column fixation was performed in 39/48 (81.3%) patients. 52% (25/48) included subtalar arthrodesis. Beaming constructs had higher re-operation rates (57.9% versus 27.6%, p < 0.05), and higher hardware failure rates (57% versus 6.9%, p< 0.001). IM nail group had higher union rates (75.9% versus 31.6%, p = 0.001), and higher rates of full weight-bearing at final follow up (86.2% versus 68%, p < 0.05). Two (4.2%) patients required amputation. Conclusion: In a cohort of 48 feet undergoing midfoot Charcot reconstruction, the use of medial column IM nails was associated with lower reoperation rates, lower rates of hardware failure, higher union rates, and higher rates of full weightbearing at final follow-up compared with traditional screw fixation. Surgeons who treat midfoot Charcot may consider these results when planning their stabilization constructs in this high-risk patient population