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Background: Initial reports have shown the efficacy of fixed distraction for the treatment of ankle osteoarthritis. We hypothesized that allowing ankle motion during distraction would result in significant improvements in outcomes compared with distraction without ankle motion.Methods: We conducted a prospective randomized controlled trial comparing the outcomes for patients with advanced ankle osteoarthritis who were managed with anterior osteophyte removal and either (1) fixed ankle distraction or (2) ankle distraction permitting joint motion. Thirty-six patients were randomized to treatment with either fixed distraction or distraction with motion. The patients were followed for twenty-four months after frame removal. The Ankle Osteoarthritis Scale (AOS) was the main outcome variable.Results: Two years after frame removal, subjects in both groups showed significant improvement compared with the status before treatment (p < 0.02 for both groups). The motion-distraction group had significantly better AOS scores than the fixed-distraction group at twenty-six, fifty-two, and 104 weeks after frame removal (p < 0.01 at each time point). At 104 weeks, the motion-distraction group had an overall mean improvement of 56.6% in the AOS score, whereas the fixed-distraction group had a mean improvement of 22.9% (p < 0.01).Conclusion: Distraction improved the patient-reported outcomes of treatment of ankle osteoarthritis. Adding ankle motion to distraction showed an early and sustained beneficial effect on outcome. [ABSTRACT FROM AUTHOR]

Background: Investigators seeking to understand the impact of musculoskeletal disorders commonly use validated outcome instruments to assess the effect of diseases on physical function and quality of life. However, the influence of concomitant systemic or musculoskeletal comorbidities on these scores has not been widely considered in orthopaedic research. The purpose of this study was to determine how morbidity unrelated to the ankle influences the perception of physical function and pain by patients with ankle osteoarthritis.Methods: Short Form-36 (SF-36) Physical Component Summary (PCS) and Mental Component Summary (MCS) scores, Ankle Osteoarthritis Scale (AOS) pain scale scores, demographic data, and systemic and musculoskeletal comorbidities were determined prospectively for 195 patients with ankle osteoarthritis and ninety-five age and gender-matched controls. The effect of systemic and musculoskeletal comorbidities on each of the scores was determined.Results: On the average, patients with ankle osteoarthritis had a relatively normal MCS score (47 +/- 13 points) and a markedly diminished PCS score (32 +/- 8 points). Both of these scores averaged 50 +/- 9 points in the control group. The AOS pain score averaged 61 +/- 23 points in the group with ankle osteoarthritis, whereas it averaged 10 +/- 15 points in the control group. We found the perception of ankle pain by patients with ankle osteoarthritis to be significantly and linearly associated with the number of other musculoskeletal problems (not related to the foot or ankle).Conclusions: The degree of physical impairment associated with ankle osteoarthritis, as measured with the SF-36, is equivalent to that reported to be associated with severely disabling medical problems including end-stage kidney disease and congestive heart failure. The perception of ankle health status as measured with a validated, patient-oriented, anatomically specific instrument is influenced by the patients' perception of their overall musculoskeletal comorbidity status. The authors of clinical studies using these instruments should adjust for concomitant musculoskeletal disease. [ABSTRACT FROM AUTHOR]

Background: Although total contact casts are highly effective in the treatment of plantar ulcerations in patients with diabetes mellitus, they are not widely used. One reason for this lack of acceptance may be the difficulty in complying with an initial period of non-weight-bearing, as is generally recommended by physicians. We performed this study to assess the effects of early weight-bearing on the healing rates of plantar ulcers in patients with diabetes who were wearing a total contact cast.Methods: Forty patients with diabetes mellitus who had a noninfected forefoot or midfoot ulcer were treated with total contact casts until healing or for thirteen weeks. The patients were instructed to bear no weight on the cast for forty-eight hours after it was applied. Using an embedded step counter, we measured the number of steps taken during the first twenty-four and forty-eight hours, the first week, and each subsequent two-week period after application of the cast. We removed the cast, measured the radius of the ulcer, and then reapplied the cast at the end of the first week and of each subsequent two-week period after cast application until the ulcer healed or for thirteen weeks. We then determined the effect of the number of steps during various time intervals on the rate of ulcer healing (defined as a change in the ulcer radius).Results: Most patients walked on the cast in the immediate postoperative period. The effects of modest amounts of early weight-bearing on ulcer healing rates appear negligible. Only excessive walking during the first twenty-four or forty-eight hours after cast application is likely to prolong the duration of cast treatment.Conclusions: Moderate early weight-bearing retards healing of plantar ulcers only minimally in patients with diabetes mellitus treated with total contact casts. Allowing patients to walk immediately after placement of a total contact cast may improve their acceptance of this form of therapy.Level Of Evidence: Therapeutic study, Level II-1 (prospective cohort study). See Instructions to Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Amputations are rarely performed solely for pain relief because of concerns regarding the persistence of pain and disability after the procedure. The purpose of this study was to assess the outcome of below-the-knee amputations performed to relieve intractable foot and ankle pain.Methods: A chart review was conducted to identify all below-the-knee amputations that had been performed for the treatment of chronic foot and ankle pain by three orthopaedic foot and ankle specialists at three institutions. The inclusion criteria included (1) intractable foot or ankle pain as the surgical indication, (2) failure of maximal medical therapy, (3) failure of prior surgical reconstruction, and (4) a minimum follow-up period of twenty-four months after below-the-knee amputation. Patients with diabetes mellitus, peripheral vascular occlusive disease, or peripheral neuropathy were excluded. Each participant completed a two-part questionnaire with regard to the levels of disability, function, pain, and recreational activity both before and after the amputation.Results: Twenty patients met the inclusion criteria, and eighteen completed the study. The study group included four women and fourteen men who had an average age of forty-two years (range, twenty-six to sixty-one years) and were followed for an average of forty-one months (range, twenty-five to eighty-five months) after the amputation. When asked whether they would have the below-the-knee amputation done again under similar circumstances, sixteen patients said yes, one was unsure, and one said no. The same distribution was observed when the patients were asked whether they were satisfied with the outcome: sixteen said yes, one was unsure, and one said no. Disability, pain, and recreational status were assessed with a 10-cm visual analog scale. After the amputation, the patients reported a decrease in both pain frequency (with the average score improving from 9.8 to 1.7; p < 0.0001) and pain intensity (with the average score improving from 8.4 to 2.6; p < 0.0001). Ten patients discontinued the use of narcotics, and seven decreased the level and/or dosage. Three patients worked before the amputation, and eight worked after the amputation. The average walking distance increased from 0.3 to 0.8 mile (p = 0.0034).Conclusion: In selected patients, a below-the-knee amputation may be a good salvage procedure for intractable foot and ankle pain that is unresponsive to all medical and local surgical reconstructive techniques. [ABSTRACT FROM AUTHOR]

Background: Ankle arthrodesis is considered by many to be the standard operative treatment for end-stage ankle arthritis; however, the long-term effect of ankle arthrodesis on other lower-extremity joints remains largely unknown. The purpose of this study was to perform a clinical and radiographic review to determine the effect of ankle arthrodesis on the development of osteoarthritis in other lower-extremity joints.Methods: Twenty-three patients who had had an isolated ankle arthrodesis for the treatment of painful posttraumatic arthritis of the ankle were followed for a mean of twenty-two years (range, twelve to forty-four years) after the operation. Each completed standardized, self-reported outcome questionnaires (the Foot Function Index, Western Ontario and McMaster University Osteoarthritis Index [WOMAC], and Short Form-36 [SF-36]), was examined clinically by two of the investigators, and underwent complete radiographic examination of the knee, ankle, and foot bilaterally. The radiographic grade of osteoarthritis was determined for each joint, and the levels of overall activity limitation, pain, and disability were determined for each patient from the clinical findings and questionnaire information.Results: Osteoarthritis of the ipsilateral subtalar (p<0.0001), talonavicular (p<0.0001), calcaneocuboid (p<0.0001), naviculocuneiform (p = 0.0012), tarsometatarsal (p = 0.0009), and first metatarsophalangeal joints (p = 0.0012) was consistently more severe than the osteoarthritis of those joints on the contralateral side. Osteoarthritis did not develop more frequently in the ipsilateral knee or lesser metatarsophalangeal joints than it did on the contralateral side. Significant differences between the two sides were found with regard to overall activity limitation (p<0.0001), pain (p<0.0001), and disability (p<0.0001), with the involved side consistently more symptomatic.Conclusions: To our knowledge, the present series represents the longest follow-up study of ankle arthrodesis to date. Our cohort of patients all had isolated post-traumatic ankle arthritis, and each underwent a successful isolated ankle arthrodesis. At a mean of twenty-two years, the majority of the patients had substantial, and accelerated, arthritic changes in the ipsilateral foot but not the knee. They were often limited functionally by foot pain. Although ankle arthrodesis may provide good early relief of pain, it is associated with premature deterioration of other joints of the foot and eventual arthritis, pain, and dysfunction. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the accessible area of the talar dome through 2 standard posterior approaches [posteromedial (PM) and posterolateral (PL)] with and without distraction., Methods: A standard PM or PL approach was performed with and without external fixator distraction on 12 through-knee cadaveric legs (6 matched pairs). The accessible area of the talar dome was outlined and imaged in a microcomputed tomography scanner to achieve 3D reconstructions of the accessible surface area. The study outcomes were accessible surface area of the talar dome in (1) total surface area and (2) sagittal plane distance of the talar dome at predetermined intervals., Results: The PM approach provided significantly more access to the talar dome than did the PL approach both with and without distraction (P < 0.001). The PM approach allowed access to 15.8% (SD = 4.7) of the talar dome without distraction and 26.4% (SD = 8.0, P < 0.001) of the talar dome with distraction. The PL approach provided access to 6.69% (SD = 2.69, P = 0.006 compared with PM) and 14.6% (SD = 6.24, P = 0.006 compared with PM) of the talar dome surface area without and with distraction. At the difficult to access posterocentral region (L50) of the talus, the PM approach without and with distraction allowed 26.7% (SD = 4.1) and 38.6% (SD = 5.6, P < 0.001) sagittal plane access compared with 18.7% (SD = 5.61, P = 0.03) and 27.5% (SD = 7.11, P = 0.003) through a PL approach., Conclusion: The PM approach provides greater access to the posterocentral and PM talus. Using an external fixator for distraction can improve intraoperative visualization by at least 40%. This study provides a roadmap that can help guide talar dome surgical access for treatment of posterior talus fractures and help determine when an approach that includes an osteotomy can be avoided., Competing Interests: The authors report no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: In orthopaedic trauma, patients' functional status scores cannot be collected before injury. Due to the lack of these data, it is difficult to reliably determine if patients have returned to their preinjury level of physical function. The goal of this article is to determine if patients' assessment of preinjury function agrees with that of familiar proxies, to determine whether patient assessment of preinjury function may be regarded as reliable., Methods: At first postinjury outpatient follow up, orthopaedic trauma patients and their proxies were asked to independently complete the PROMIS physical function computer adaptive test (PF CAT) based on how they perceived the function of the patient before injury. Intraclass correlation, paired sample t tests, and 95% confidence intervals were used to analyze patient-proxy agreement., Results: Fifty patient-proxy pairs completed the questionnaire at an average of 14.3 (SD = 1.1) days postoperative (average 19.3, SD = 12.1 days postinjury). Patient mean PF CAT score was 57.92 (SD = 10.38) for patients and 56.59 (SD = 11.50) for proxies. Paired samples t test showed that patient's PF CAT scores were not significantly different from proxy scores [mean score difference = 1.33; 95% CI = (-1.28, 3.94); P = 0.311]. Intraclass correlation between patient and proxy scores was 0.79. There was no notable bias., Discussion: Good agreement in PF CAT preinjury assessment between patients and proxies support patients' ability to report reliable preinjury physical functioning in the early postinjury setting using the PF CAT.

Purpose: Patient-reported outcomes are important to assess effectiveness of clinical interventions. For orthopaedic trauma patients, the short Musculoskeletal Function Assessment (sMFA) is a commonly used questionnaire. Recently, the Patient-Reported Outcome Measurement Information System (PROMIS) PF Function Computer Adaptive Test (PF CAT) was developed using item response theory to efficiently administer questions from a calibrated bank of 124 PF questions using computerized adaptive testing. In this study, we compared the sMFA versus the PROMIS PF CAT for trauma patients., Methods: Orthopaedic trauma patients completed the sMFA and the PROMIS PF CAT on a tablet wirelessly connected to the PROMIS Assessment Center. The time for each test administration was recorded. A 1-parameter item response theory model was used to examine the psychometric properties of the instruments, including precision and floor/ceiling effects., Results: One hundred fifty-three orthopaedic trauma patients participated in the study. Mean test administration time for PROMIS PF CAT was 44 seconds versus 599 seconds for sMFA (P < 0.05). Both instruments showed extremely high item reliability (Cronbach alpha = 0.98). In terms of instrument coverage, neither instrument showed any floor effect; however, the sMFA revealed 14.4% ceiling effect, whereas the PROMIS PF CAT had no appreciable ceiling effect., Conclusions: Administered by electronic means, the PROMIS PF CAT required less than one-tenth the amount of time for patients to complete than the sMFA while achieving equally high reliability and less ceiling effects. The PROMIS PF CAT is a very attractive and innovative method for assessing patient-reported outcomes with minimal burden to patients.

Purpose: We present the imaging features of longitudinal stress fractures in eight patients and evaluate the literature to determine which tests are most useful for making this diagnosis., Method: Three musculoskeletal radiologists retrospectively reviewed eight cases of longitudinal tibial stress fractures presenting between 1988 and 1994. Reports on 36 cases, cited in the literature between 1960 and 1996, also were reviewed. Imaging modalities used and characteristic imaging features were noted., Results: Plain radiographs had a characteristic appearance in approximately 28% of patients. Initially, plain films were negative, and in most cases, they eventually showed characteristic radiographic features. However, 25% of cases failed to demonstrate a plain film abnormality, with the diagnosis made by other modalities. CT or MRI is often diagnostic, and longitudinal stress fractures have characteristic imaging features with each modality. While sensitive, bone scan has lower specificity than either CT or MRI., Conclusion: Longitudinal stress fractures have characteristic imaging features, and familiarity with these features is necessary for timely and efficient diagnosis, avoiding morbidity due to delay or use of unnecessary tests.

Objective: To explore the relationship between urinary incontinence in elite nulliparous athletes and force absorption on impact, as assessed by foot arch flexibility., Methods: One investigator measured medial longitudinal arch height in two gait stances (neutral and maximally dorsiflexed ankle positions) in 47 female varsity athletes representing five sports. Each athlete completed a questionnaire about urinary incontinence prevalence. We compared the change in arch height between the two gait stances with the prevalence of urinary incontinence., Results: There was a statistically significant association between decreased foot flexibility and urinary incontinence; the mean percent change in arch height was 8.94 +/- 0.08% (standard deviation) in incontinent women and 13.70 +/- 0.09% in continent women (P = .03)., Conclusion: How impact forces are absorbed may be one potential etiology for stress incontinence. An improved understanding of how impact forces are transmitted to the pelvic floor could provide important information about potential preventive interventions for urinary incontinence and other pelvic floor disorders, such as genital prolapse.

Seventeen patients with 18 open talar fracture-dislocations or total dislocations of the talus were reviewed to determine the functional outcome and incidence of infection. Seven of 18 feet (38%) developed infection. Infection was associated with extrusion of the talar body through the open wound (p < 0.025). Final follow-up was achieved in 13 of 17 patients (14 of 18 feet) at an average of 7 years and 4 months after injury. According to the Boston Children's Hospital ankle grading system, the overall results were considered excellent in one, good in five, fair in two, and failures in six feet. The data suggest a greater proportion of failures in the infected group compared with the non-infected group (p = 0.05).

Multiple endocrine neoplasia type 2b (MEN 2b) is a rare genetic disorder. Affected individuals have malignant thyroid tumors, pheochromocytoma, and ganglioneuromatosis. The musculoskeletal manifestations of MEN 2b include a Marfanoid habitus, pes cavus, scoliosis, slipped capital femoral epiphysis, joint laxity, poor muscle development, and delayed maturation. The initial clinical presentation of MEN 2b frequently involves the musculoskeletal system. The characteristics ganglioneuromatosis of the lips and tongue, however, should alert the orthopedic surgeon to the underlying disorder. Effective treatment of the malignant neoplasms hinges on early diagnosis. The risk of perioperative hypertensive crisis is significant; it may be prevented by appropriate treatment of the pheochromocytoma.