Evaluation of Heat Generation in Unidirectional Versus Oscillatory Modes During K‐Wire Insertion in Bone

Heat generation during insertion of Kirschner wires (K‐wires) may lead to thermal osteonecrosis and can affect the construct fixation. Unidirectional and oscillatory drilling modes are options for K‐wire insertion, but understanding of the difference in heat generation between the two modes is lacking. The goal of this study was to compare the temperature rise during K‐wire insertion under these two modes and provide technical guidelines for K‐wire placement to minimize thermal injury. Ten orthopedic surgeons were instructed to drill holes on hydrated ex vivo bovine bones under two modes. The drilling trials were evaluated in terms of temperature, thrust force, torque, drilling time, and tool wear. The analysis of variance showed that the oscillatory mode generated significantly lowered peak bone temperature rise (13% lower mean value, p = 0.036) over significantly longer drilling time (46% higher mean time, p < 0.001) than the unidirectional mode. Drilling time had significant effect on peak bone temperature rise under both modes (p < 0.001) and impact of peak thrust force was significant under oscillatory mode (p < 0.001). These findings suggest that the drilling mode choice is a compromise between peak temperature and bone exposure time. Shortening the drilling time was the key under both modes to minimize temperature rise and thermal necrosis risk. To achieve faster drilling, technique analysis found that “shaky” and intermittent drilling with moderate thrust force are preferred techniques by small vibration of the drill about the K‐wire axis and slight lift‐up of the K‐wire once or twice during drilling. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:1903–1909, 2019Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/151349/1/jor24345_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/151349/2/jor24345.pd

Effect of McGlamry Elevator Placement on the Plantar Plate Origin

Category: Lesser Toes Introduction/Purpose: Lesser metatarsal phalangeal (MTP) joint plantar plate tears have been implicated in a variety of lesser toe pathologies, and plantar plate repair (PPR) through a dorsal approach has become increasingly popular as a treatment of lesser toe deformities and lesser MTP instability. With the aid of a McGlamry elevator, releasing the collateral ligaments and micro-suture passing techniques, the plantar plate is repaired under direct visualization. While this approach is seen as a reliable alternative, the consequence of this technique on local MTP joint anatomy is not yet well understood. The purpose of this study is to describe the proximal plantar plate attachment and to quantify the amount of soft tissue disruption of the lesser toe MTP joint anatomy with insertion of a McGlamry elevator. Methods: Fresh frozen human cadaveric feet were dissected, and the proximal plantar plate attachment of the second, third, and fourth toe MTP joints (n=6) were examined, focusing on the relationship of structures connecting the distal metatarsal shaft and head to the plantar plate. The accessory collateral ligament insertions and proximal plantar plate attachments were measured using digital calipers. Next, the second, third, and fourth rays (n=12) of separate fresh frozen cadaveric specimens were isolated. An 11mm McGlamry elevator was then inserted in standard surgical fashion in both a more shallow (limited exposure) and deeper (greater exposure) position. Using mini C-arm fluoroscopy, radiographs were taken in both positions, and the depth of insertion along the metatarsal was measured. Results: The proximal plantar plate attachment to the metatarsal is most robust just proximal to the lateral articular margin and this attachment extends an average of 10.42mm (SD= 2.71mm) proximally along the metatarsal neck and shaft. In addition there are stout proximal plantar plate attachments at the bilateral insertion sites of the accessory collateral ligament (ACL) which are thick and broad with an average insertion length of 9.01mm (SD=1.35mm). Insertion of a McGlamry elevator resulted in stripping of the distal plantar soft tissues over an average of 21.58% of the total metatarsal length (SD=4.43%) for shallow placement and 34.87% (SD=4.40%) for deep placement with a significant difference of 7.96% between the two positions (p<.00001). Conclusion: Current techniques of plantar plate repair through a dorsal approach require releasing collateral ligaments and proximal stripping of the plantar plate from the metatarsal for adequate visualization. We suggest that this significantly destabilizes the metatarsal from the plantar plate as it strips approximately the distal most one third of the metatarsal including all major proximal plantar plate attachments to the metatarsal. As surgical techniques continue to evolve and improve, surgeons should consider avoiding the placement of a McGlamry elevator as this can destabilize the proximal attachment of the plantar plate to the metatarsal

Should We Fix Them? A Comparison of Outcomes at Mid-Term Follow-Up of Operatively and Non- Operatively Treated Weber B Ankle Fractures

Category: Trauma; Ankle Introduction/Purpose: Our group previously presented a novel protocol for non-operative management of Weber B ankle fractures with medial clear space (MCS) < 7mm on gravity stress (GS) radiographs and within 2mm of ipsilateral superior clear space and contralateral GS MCS. The goal of this study is to recruit an operative cohort for comparison of clinical, radiographic, and patient reported outcomes. Methods: We recruited a cohort of patients who may have been considered for the non-operative protocol but underwent surgery instead. Outcome measures were obtained including Kellgren-Lawrence scale for evaluation of arthritis, American Orthopedic Foot & Ankle Society (AOFAS) Hindfoot, Olerud Molander Ankle (OMA), Lower Extremity Functional Scale (LEFS), and PROMIS (physical function, depression, pain interference) scores. This data was then compared to the non-operative cohort. Results: There were 20 patients in the operative cohort and 29 in the original non-operative cohort. Mean follow-up was 6.9 and 6.7 years, respectively. Average outcome scores were as follows for the operative and non-operative groups, respectively: LEFS, 68.1 and 75.2 (p=0.009); OMA, 89.0 and 94.1 (p=0.05); AOFAS, 91.7 and 98.5 (p=0.0003); PROMIS Physical Function, 50.4 and 58.2 (p=0.01); PROMIS Depression, 45.4 and 42.8 (p=0.29); PROMIS Pain Interference, 49.7 and 42.2 (p=0.004). All patients in both groups achieved union of their fracture. There was no difference in Kellgren-Lawrence arthritis scores though interobserver reliability for scoring was poor. In the surgical cohort there were 3 (15%) cases of implant removal, 1 (%) SPN neurapraxia, and 1 (%) delayed wound healing. Conclusion: In carefully selected patients with isolated Weber B fractures and MCS < 7mm on gravity stress radiographs that is within 2mm of ipsilateral superior clear space and contralateral GS MCS, non-operative management may be considered as it can lead to equivalent or superior outcomes with none of the risks typically associated with surgical intervention

Lateral Talar Subluxation Measurements in Non-Operatively Managed Weber B Ankle Fractures

Category: Ankle; Trauma Introduction/Purpose: Isolated Weber B ankle fractures are common orthopedic injuries; however, indications for surgical management can be controversial. Stress radiographs have been utilized to evaluate the competence of the deltoid ligament, and recently lateral talar subluxation (LTS) has been described as a measurement tool for evaluating these injuries. It has been suggested that LTS >4mm on gravity stress radiographs may be utilized to determine need for surgical intervention. In this study we review the LTS measurements in a cohort of non-operatively treated isolated Weber B fibula fractures to determine its utility as a tool to potentially guide treatment decisions and its association with patient outcomes. Methods: Our group previously presented a novel algorithm for non-operative management of isolated Weber B ankle fractures and enrolled a cohort of patients. Outcome scores were reported including American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot, Olerud-Molander (OMA), Foot and Ankle Ability Measure for Activities of Daily Living (FAAM/ADL), and Visual Analog Scale (VAS) scores. All patients achieved union of their fracture. For each patient we measured LTS on the injury gravity stress view x-rays as well as the un-injured contralateral side which has not been previously reported. A Kruskal-Wallis non-parametric test was used to determine whether there was any association of outcomes with extent of LTS. Results: 42 patients were included, with minimum 1 year follow-up. The average age was 49 years (range 19 to 72). On injury gravity stress radiographs, mean medial clear space (MCS) was 4.45 mm (SD = 0.93), superior clear space (SCS) 3.46 mm (SD = 0.70), and LTS 2.33 mm (SD = 1.57, range 0 – 4.7 mm), with 35 (83.3%) patients having LTS ≤ 4 mm. Contralateral (un-injured) gravity stress mean MCS was 3.39 mm (SD = 0.63), SCS 3.15 mm (SD = 0.50), and LTS 1.30 mm (SD = 1.28, range 0 - 4.8). There was no significant difference in outcome measures based on amount of LTS ( 4 mm): AOFAS (p=0.41), OMA (p=0.40), FAAM/ADL (p=0.41), pain VAS (p=0.16). Conclusion: All patients in our cohort were successfully treated non-operatively. Most patients had injury LTS ≤ 4 mm, although those with LTS >4 mm had excellent outcome scores as well. Amount of LTS did not correlate with outcomes. We present a large range of LTS measurements in normal ankles, which may be attributed to the high variability of these measurements and sensitivity to ankle rotation on radiographs. LTS may be a useful adjunct in evaluating isolated Weber B ankle fractures but may not be entirely reliable on its own. Further studies are required to validate LTS as a quantitative decision-making tool

New Persistent Opioid Use Following Common Forefoot Procedures for Treatment of Hallux Valgus

Category: Bunion Introduction/Purpose: Chronic opioid use and abuse is one of the greatest public health challenges in the United States and continues to worsen. Orthopaedic surgeons stand at #4 on the list of top prescribers of opioid analgesics by specialty and are squarely positioned to have an impact on the problem. A recent study revealed an 8% prevalence of new persistent opioid usage following abdominal surgery. At present, the incidence of persistent opioid use after foot and ankle surgery is largely unknown. Operative bunion correction is one of the most commonly performed elective foot and ankle surgeries in this country. We sought to determine the incidence of new persistent opioid use following surgical treatment of hallux valgus and to identify patient factors associated with persistent opioid use. Methods: A nationwide insurance claims data set from January 2010 to June 2015 was used to identify opioid naive patients (defined as patients with no prior opioid use 12 months prior to injury) who underwent surgical treatment of hallux valgus with either a proximal or distal first metatarsal osteotomy. The incidence of new persistent opioid use, defined by opioid prescription fulfillment between 90 and 180 days after surgery was then calculated. Data were assessed for patient factors which may be predictors of new persistent opioid use including surgery type, health insurance type, age, gender, household income, and comorbidities. Results: A total of 38,312 patients underwent surgical treatment of hallux valgus with either a distal or proximal first metatarsal osteotomy and filled a perioperative opioid prescription. The rate of new persistent opioid use among all patients was 5.6%. The majority of patients (90%) underwent treatment with a distal metatarsal osteotomy. Patients who underwent treatment with a proximal metatarsal osteotomy were more likely to have new persistent opioid use (aOR: 1.16; p=0.04). Logistic regression analysis demonstrated that patient factors independently associated with new persistent opioid use included depression, anxiety, alcohol and substance abuse disorders, and certain preoperative pain disorders. Age, gender, and income were not associated with new persistent opioid use. Conclusion: Despite rising national attention, opioid abuse continues to be a growing epidemic. In order for foot and ankle surgeons to help solve this problem, it must first be better defined. New persistent opioid use following surgical treatment of hallux valgus affects a substantial, growing number of patients. Fifty percent of patients using opioids for 3 months will be using them at 5 years. Understanding patient factors associated with persistent opioid use can help clinicians identify and counsel at-risk patients and ultimately focus strategies and interventions aimed at mitigating and eliminating this massive public health problem

JAAOS-d-14-00031 333..339

Abstract Anterior ankle impingement is a common clinical condition characterized by chronic anterior ankle pain that is exacerbated on dorsiflexion. Additional symptoms include instability; limited ankle motion; and pain with squatting, sprinting, stair climbing, and hill climbing. Diagnosis is typically confirmed with plain radiographs. Nonsurgical management includes physical therapy, strengthening exercises, activity modification, bracing, and anti-inflammatory medication. Although arthroscopic treatment is sufficient in some patients, most require an open approach to address related pathology. We advocate aggressive range of motion as well as weight bearing postoperatively. Further study is needed to confirm current understanding of anterior ankle impingement and to better define treatment options and prevention strategies

Microvasculature of the Plantar Plate Using Nano-Computed Tomography

Category: Basic Sciences/Biologics, Lesser Toes, Midfoot/Forefoot Introduction/Purpose: Lesser toe plantar plate attenuation or disruption is being increasingly implicated in a variety of very common clinical complaints including metatarsalgia, metatarsal-phalangeal (MTP) joint subluxation and dislocation, hammertoe, crossover toe, etc. A multitude of surgical techniques and devices have been recently developed to facilitate surgical repair of the plantar plate. However, the microvascular anatomy, and therefore the healing potential in large part, has not been addressed. We sought to answer this question by employing a novel technique involving microvascular perfusion and nano-computed tomography (Nano-CT) imaging. Methods: 12 human adult cadaveric lower extremities were amputated distal to the knee. The anterior and posterior tibial arteries were dissected and cannulated proximal to the ankle joint and were perfused with a barium solution. The soft tissues of each foot were then counterstained with phosphomolybdic acid (PMA). The 2nd through 4th toe MTP joints of 12 feet were imaged with Nano-CT at 14-micron resolution. Images were then reconstructed for three-dimensional analysis of the plantar plate microvasculature and calculation of the vascular density along the length of the plantar plate. Results: A microvascular network extends from the surrounding soft tissues at the attachments of the plantar plate on both the metatarsal and proximal phalanx. The mid-substance of the plantar plate appears to be relatively hypovascular. Analysis of the vascular density along the length of the plantar plate demonstrated a consistent trend with increased vascular density at approximately the proximal 30% and distal 20% of the plantar plate (Figure 1). Conclusion: There is a vascular network extending from the surrounding soft tissues into approximately the proximal 30% and the distal 20% of the plantar plate. The hypovascular mid-portion of the plantar plate may play an important role in the underlying patho-anatomy and pathophysiology of this area. We believe our findings likely have significant clinical implications for the reparative potential of this region, and therefore the surgical procedures currently described to accomplish anatomic plantar plate repair