Approximation of the Ankle-Brachial Index in the Setting of Medial Arterial Calcific Sclerosis

The presence of medial arterial calcific sclerosis is known to cause inaccuracy in the interpretation of noninvasive vascular testing. This substantially limits the utility of an important baseline diagnostic test for peripheral arterial disease. Therefore, the objective of this investigation was to derive a method to effectively factor out calcification in the interpretation of the ankle and digital brachial indices. The noninvasive vascular testing results of 160 subjects were stratified into the absence of calcification, mild calcification, moderate calcification, and severe calcification based on plain film radiographic findings of the infrageniculate vessels. Measurements were then performed of the pulse volume recording (PVR) waveforms at brachial, ankle and digital anatomic levels to include PVR wavelength and PVR upstroke length, with a calculation of the ratio of PVR upstroke length to PVR wavelength. These measurements were compared between groups and then correlated to the ankle and digital brachial indices. A significant difference was observed in the PVR upstroke ratio between the 3 anatomic levels (0.1818 vs 0.2622 vs 0.3191; p < .001), but not between the 4 calcification groups (0.2457 vs 0.2363 vs 0.2694 vs 0.2631; p = .242). A significant negative correlation was observed between the PVR upstroke ratio and the ankle brachial index (ABI) (Pearson -0.454; p = .002) with linear regression indicating the relationship is defined by the formula: Effective ankle brachial index = 1.17 - (1.33 × PVR upstroke ratio at ankle level). A significant negative correlation was also observed between the PVR upstroke ratio and the digital brachial index (Pearson -0.553; p < .001) with linear regression indicating the relationship is defined by the formula: Effective toe brachial index = 1.04 - (1.61 × PVR upstroke ratio at digital level). The results of this investigation demonstrate the feasibility of, and provide equations to approximate, the effective ankle brachial and toe brachial indices in the setting of medial arterial calcification.

Anatomic and Treatment Descriptive Features of Foot Infections Presenting With Radiographic Soft Tissue Emphysema

Foot infections associated with soft tissue emphysema, or the radiographic appearance of gas, are widely considered to necessitate urgent decompression with excisional debridement of the necrotic and infectious tissue burden. The objective of this investigation was to describe anatomic features and clinical outcomes associated with the presence of soft tissue emphysema in foot infections. A retrospective chart review was performed of 62 subjects meeting selection criteria. These were primarily male (74.2%), with a history of diabetes mellitus (85.5%), and without a history of previous lower extremity revascularization (98.4%). The primary radiographic location of the soft tissue emphysema was most frequently in the forefoot (61.3%), followed by the midfoot (21.0%), and rearfoot (16.1%). The soft tissue emphysema was most frequently observed primarily in the dorsal foot tissue (49.2%), followed by both dorsal and plantar foot tissue (27.4%), and the plantar foot tissue (24.2%). The soft tissue emphysema was confined to the primary anatomic location in 74.2% of subjects, while 25.8% of cases demonstrated extension into a more proximal anatomic area. Eighty-two percent of subjects underwent a bedside incision and drainage procedure on presentation in the emergency department, and 95.2% underwent a formal incision and drainage procedure in the operating room at 1.05 ± 0.79 (0-5) postadmission days. Twenty-seven percent of subjects had an unplanned 30-day readmission and 17.7% underwent an unplanned reoperation within 30 days following the index discharge. Fifty-two percent of subjects underwent a minor or major amputation during the index admission, while 33.9% eventually resulted in major limb amputation within 12 months. We hope that this investigation adds to the body of knowledge and provides expectations with respect to the evaluation and treatment of foot soft tissue infections complicated by the presence of radiographic soft tissue emphysema.

A Comparison of Adverse Short-Term Outcomes Following Forefoot Amputation Performed on an Inpatient Versus Outpatient Basis

The objective of this investigation was to evaluate short-term adverse outcomes following forefoot amputation with a specific comparison between those procedures performed on an inpatient versus outpatient basis. The 2018 American College of Surgeons National Surgical Quality Improvement Program database was interrogated to select those subjects with a 28805 current procedural terminology code (amputation, foot; transmetatarsal) that underwent the procedure with "all layers of incision (deep and superficial) fully closed." This resulted in 326 subjects who underwent the procedure on an inpatient basis and 72 subjects who underwent the procedure on an outpatient basis. Results of the primary outcome measures found no significant differences between groups with respect to the development of a superficial surgical site infection (5.8% vs 5.6%; p = .950), deep incisional infection (3.4% vs 5.6%; p = .380), or wound disruption (3.4% vs 6.9%; p = .163). Additionally, no significant differences were observed between groups with respect to unplanned reoperations (15.6% vs 12.5%; p = .500) or unplanned hospital readmissions (21.8% vs 23.6%; p = .957). The results of this investigation demonstrate no difference in short-term adverse outcomes following the performance of forefoot amputation with primary closure when the procedure is performed on an inpatient or outpatient basis. We hope that this information is utilized in future investigations specifically examining this clinical scenario as it relates to hospital admission criteria related to lower extremity tissue loss, length of hospital stay considerations, the timing of partial foot amputation following revascularization, and the economics of limb preservation.

An Evaluation of Patient Characteristics Associated With Medical Disposition in the Surgical Treatment of Ankle Fractures

The objective of this investigation was to evaluate patient characteristics associated with medical disposition in treatment of ankle fractures. The 2018 American College of Surgeons National Surgical Quality Improvement Program database was interrogated with data extracted related to the 6 current procedural terminology (CPT) codes available pertaining to ankle fractures: 27766, 27769, 27792, 27814, 27822, and 27823. The primary outcome analysis involved a comparison of patient characteristics and short-term adverse outcomes between those fractures repaired on an inpatient basis versus outpatient basis. A secondary analysis was then performed on patient characteristics and adverse short-term outcomes between those fractures treated on an inpatient basis who were discharged home versus elsewhere. Age (p < .001), race (p < .001), ethnicity (p < .001), body mass index (BMI) (p < .001), estimated probability of mortality (p < .001), estimated probability of morbidity (p < .001), CPT code of fracture designation (p < .001), functional status (p < .001), elective surgery designation (p < .001), American Society of Anesthesiologists class (p < .001), diabetes (p < .001), smoking status (p < .001), dyspnea (p < .001), COPD (p < .001), congestive heart failure (p < .001), hypertension (p < .001), dialysis (p < .001), cancer (p < .001), steroid use (p < .001), blood transfusion history (p < .001), and sepsis/systemic inflammatory response syndrome history (p < .001) were all independently associated with the ankle fracture repair being performed on an inpatient basis on regression analysis. Age (p < .001), race (p = .025), ethnicity (p < .001), BMI (p = .001), CPT code of fracture designation (p < .001), preoperative functional status (p < .001), and American Society of Anesthesiologists class (p < .001) were all independently associated with inpatient ankle fracture repairs being discharged to home following the procedure on regression analysis. The results of this investigation demonstrate that differences in patient demographic characteristics might contribute to medical decision-making as it relates to patient management and discharge disposition in the treatment of ankle fractures.

Descriptive Quantitative Analysis of First Metatarsal Sagittal Plane Motion

Evaluation of the sagittal plane motion of the first ray is a commonly accepted physical examination technique performed during the assessment and treatment of the hallux valgus deformity. Excessive or abnormal motion in this location, termed "hypermobility," has also traditionally been strongly associated with surgical decision-making and serves as a widely accepted indication for performance of the first metatarsal-medial cuneiform arthrodesis procedure. The objective of this investigation was to perform an analysis of first ray sagittal plane motion from a large population in order to determine the descriptive quantitative characteristics of the data set. First metatarsal sagittal plane motion was measured from a group of 149 subjects (298 feet) with a Klaue device. The mean total first metatarsal sagittal plane motion was 9.37 ± 2.39 mm (3.97-18.76). The data set was found to demonstrate many of the characteristics of a normally distributed population based on the histogram distribution, skewness (0.651), and kurtosis (0.761). No difference was observed between measurement of total sagittal plane motion between right and left feet (9.13 ± 2.37 mm vs 9.61 ± 2.40 mm; p = .081), nor between male and female subjects (9.29 ± 2.27 mm vs 9.58 ± 2.70 mm; p = .352). No substantial correlation was observed between total sagittal plane motion and subject age (Pearson correlation -0.053; p = .522). Results indicate that first ray sagittal plane motion might be best considered as a continuous variable as opposed to categorical variable, and might help objectify the difference between "normal" and "abnormal" motion.

Evaluation of the Relationship Between Aspects of Medical Complexity and Work Relative Value Units (wRVUs) for Foot and Ankle Surgical Procedures

Work relative value units (wRVUs) have been assigned to current procedural terminology codes in an effort to help establish physician compensation. However, the ability of these to accurately and efficiently capture the time, technical, and perioperative managerial aspects required of various procedures has recently been called into question for several surgical subspecialties. Therefore, the objective of this investigation was to evaluate various measures of medical complexity against wRVUs for foot and ankle surgical procedures. The 2018 American College of Surgeons National Surgical Quality Improvement Program database was utilized to identify and extract data related to the perioperative medical complexity of 16 foot and ankle surgical current procedural terminology codes. We observed a "weak" positive relationship between wRVUs and operation time as defined by a correlation coefficient of 0.234 (p < .001). Other variables associated with medical complexity in the perioperative period were found to significantly vary between wRVUs categories, but these differences were neither consistently nor directly associated with assigned relative values. We conclude that wRVUs might not always represent an efficient means for determining compensation for foot and ankle surgical procedures.

Level of Agreement Between Systematic Doppler Examination of the Lower Extremity and Diagnostic Angiography in the Setting of Peripheral Arterial Disease

BACKGROUND

The objective of this investigation was to determine the level of agreement between a systematic clinical Doppler examination of the foot and ankle and diagnostic peripheral angiography.

METHODS

The described Doppler examination technique attempted to determine the patency, quality, and direction of the flow through the dorsalis pedis artery, posterior tibial artery, terminal branches of the peroneal artery, and vascular arch of the foot. These results were then compared with angiographic distal run-off images as interpreted by a blinded vascular surgeon.

RESULTS

Levels of agreement with respect to artery patency/quality ranged from 64.0% to 84.0%. Sensitivity ranged from 53.8% to 84.2%, and specificity ranged from 64.7% to 91.7%. Agreement with respect to arterial flow direction ranged from 73.3% to 90.5%.

CONCLUSIONS

We interpret these results to indicate that this comprehensive physical examination technique of the arterial flow to the foot and ankle with a Doppler device might serve as a reasonable initial surrogate to diagnostic angiography in some patients with peripheral arterial disease.

Evaluating the Impact of Medial Arterial Calcification on Outcomes of Infrageniculate Endovascular Interventions for Treatment of Diabetic Foot Ulcers

BACKGROUND

Medial arterial calcification (MAC) of the tibial and pedal arteries has been associated with an increased risk of amputation among people with diabetes. Endovascular interventions on infrageniculate vessels are frequently performed with the intent of treating peripheral artery disease (PAD) and decreasing the risk of amputation in those with diabetes. This study aimed to investigate how the extent of MAC impacts outcomes of endovascular procedures in people with diabetic foot ulcers (DFU).

METHODS

We identified all patients who had undergone infrageniculate angioplasty in the setting of DFU at our institution between 2009 and 2019. Subjects were assigned a MAC score based on the severity of MAC in each vessel visualized on plain radiographs of the ankle and foot. We evaluated the relationship between MAC and the primary outcome, major adverse limb event (MALE), using stratified Cox proportional modeling.

RESULTS

Among 99 subjects with DFU who had undergone infrageniculate angioplasty, MALE occurred in 50% (95% confidence interval [CI] 38%-61%) of patients within 1 year of intervention. On univariate Cox regression analysis, each 1 point increment in MAC score (hazard ratio [HR], 1.09; 95% CI 1.01-1.18), the third tertile of MAC score (HR, 2.27; 95% CI 1.01-5.11), age (HR 0.96; 95% CI 0.93-0.99), and wound grade (HR, 5.34; 95% CI 2.17-13.14), were significantly associated with increased risk of MALE. On adjusted analysis stratified by wound grade, MAC score was found to be associated with MALE only in patients with a low wound grade.

CONCLUSION

Increased severity of MAC is associated with increased risk of MALE for subjects undergoing infrageniculate angioplasty with a low wound grade. Further research is needed to better understand the complex relationships of MAC, PAD, DFU, and interventions aimed at promoting healing of DFU.

Retrospective chart review of perioperative pain management of patients having surgery for closed ankle fractures using peripheral nerve blocks at a level one trauma center

Chronic opioid use is unfortunately perceived among these postoperative patients, specifically within orthopedic surgery. Patients having orthopedic surgeries are at risk for becoming addicted to opioids, and one benefit of peripheral nerves blocks could be to provide an alternative mode of pain control. This study takes a retrospective look at the use of peripheral nerve blocks for pain control following surgery for isolated traumatic ankle injuries. We hypothesize that when peripheral nerve blocks are administered preoperatively to patients with closed ankle fractures, they will have overall better control of postoperative pain compared to patients who did not receive a peripheral nerve block.

OBJECTIVES

The objective of this investigation was to evaluate the effect of preoperative peripheral nerve blockade on pain outcomes after ankle fracture surgery.

METHODS

After approval from our institutional review board, a Current Procedural Terminology code search was performed of all patients within our institution over a 3-year data collection period (August 2016-June 2019). This resulted in 177 subjects who underwent isolated closed ankle fracture open reduction internal fixation (ORIF), of which 71 subjects met inclusion criteria.

RESULTS

Results of the primary outcome measures found no difference in the mean postoperative care unit (PACU) pain scores between the groups (2.39 ± 2.91 vs 3.52 ± 3.09; P = 0.1724) nor the frequency of those who reported only mild pain (63.0% vs 47.10%; P = 0.2704). Subjects who received a peripheral nerve block spent more time in the PACU before discharge (2.06 ± 1.05 vs 0.94 ± 1.21 hours; P = 0.0004). Subjects receiving a peripheral nerve block were more likely to be given no analgesics in the PACU (38.9% vs 11.8%; P = 0.042) and less likely to receive a narcotic analgesic in the PACU (53.7% vs 82.4%; P = 0.047).

CONCLUSION

Although the results of this investigation demonstrate no significant difference in the mean PACU pain scores, they do demonstrate a significant difference in the amount of pain medication given in the PACU setting. This information will be used for future investigations of this discrepancy between pain perception and need for immediate postoperative pain medications as it relates to multimodal pain control in the setting of ankle fracture surgery.

Attrition in Podiatric Medicine and Surgery Residency

BACKGROUND

The objective of this study was to investigate the rate of attrition within podiatric medicine and surgery residency training programs.

METHODS

Between the academic years 2006-2007 and 2015-2016, the Temple University School of Podiatric Medicine matched 780 graduates into 163 different residency training programs. Program directors from these sites were individually contacted by e-mail and asked whether the specific Temple University School of Podiatric Medicine graduates who originally matched with their program 1) completed the program, 2) transferred to another program, 3) quit the program, or 4) were fired from the program.

RESULTS

Results were returned with respect to 614 (78.7%) of the 780 graduates, representing 103 (63.2%) of the 163 training programs. Program directors reported that 573 (93.3%) of the 614 graduates completed the program, 17 (2.8%) transferred from the program, six (1.0%) quit the program, five (0.8%) were fired by the program, and 13 (2.1%) matched but never started the program. This equates to an annual attrition rate of 0.46% for residents who started the podiatric residency training program that they matched with.

CONCLUSIONS

We conclude that the rate of attrition in podiatric medicine and surgery residency training appears to be relatively low or at least in line with other medical specialties, and hope that this information leads to other investigations examining attrition, specifically as it relates to physician-specific and program-specific risk factors for attrition.

Perceived Stress of Podiatric Medical Students

BACKGROUND

The primary objective of this investigation was to objectify perceived stresses of students enrolled at a US college of podiatric medicine.

METHODS

Following preliminary pilot data collection and representative student interviews, the Perceived Stress Scale and a newly developed survey consisting of 46 potential stresses were administered to students. Participants were asked to identify up to ten items from the survey that caused them the most stress and to further identify up to three of these ten that they considered to be the most stressful.

RESULTS

A response rate of 71.5% (261 of 365) was observed. Specific results demonstrate that levels of perceived stress in podiatric medical students are higher than those in the general population, as well as some potential trends with respect to specific perceived stresses that change over time.

CONCLUSIONS

The results of this investigation provide quantitative evidence of perceived levels of stress and specific stresses of students enrolled at a US college of podiatric medicine. We hope that these findings increase awareness of stress in podiatric medicine, lead to colleges of podiatric medicine taking active steps to improve student stress education, and lead to future investigations of stress and mental health in the field of podiatric medicine.

Level of Agreement with the Microscopic Analysis of Joint Aspirate for the Diagnosis of Gout in the Lower Extremity

BACKGROUND

Although clinical findings, laboratory serum markers, and radiographic images are also used, the purported gold standard or standard reference test for the diagnosis of gout is microscopic analysis of aspirated joint fluid. This observational investigation sought to identify the level of agreement with the microscopic analysis of joint fluid aspirate for the diagnosis of gout in the lower extremity between two departments in a single health-care center.

METHODS

A retrospective medical record review identified consecutive patients seen for suspected gout who underwent diagnostic joint aspiration. Patients were included if a lower-extremity joint synovial fluid sample was obtained and were excluded if they were not independently evaluated by both the departments of rheumatology and pathology. We categorized the documented joint fluid findings into four groups: no crystals, sodium urate crystals, calcium pyrophosphate dihydrate crystals, or both sodium urate and calcium pyrophosphate dihydrate crystals. We defined a "clinically significant disagreement" as one department observing any type of crystals and the other department observing no crystals.

RESULTS

We observed a clinically significant disagreement rate of 23.26% (intraclass correlation coefficient = 0.496). The department of rheumatology was more likely to observe the presence of crystals in a sample compared with the department of pathology (88.37% versus 65.12%; P = .02).

CONCLUSIONS

These results provide evidence that microscopic analysis of joint fluid aspirate might lack the accuracy and reliability needed to be considered a gold standard diagnostic test for gout in the lower extremity.

Printed 3-Dimensional Computed Tomography Scanned Ankle Fractures as an Educational Instrument

The evaluation of and treatment protocols for ankle fractures represents an important aspect of the education of podiatric medical students. The objective of this investigation was to examine the feasibility of and student satisfaction with using 3-dimensional (3D) printed bone models representative of the Lauge-Hansen classification. The computed tomography scans of subjects with actual rotational ankle fractures representative of the Lauge-Hansen classification were identified and extracted into a format compatible with a 3D printer. The models were approximately 20 cm in height and made of acrylonitrile butadiene styrene plastic in ivory color. These were subsequently implemented into the curriculum of a traumatology course with third year podiatric medical students in the form of a hands-on workshop. Students expressed high levels of satisfaction with the use of these models, and most recommended their continued implementation within the curriculum. The results of this investigation indicate that 3D technology within podiatric medical education is feasible with high levels of student satisfaction.

Quantitative Assessment of the Obliquity of the First Metatarsal-Medial Cuneiform Articulation

The so-called obliquity of the first metatarsal-medial cuneiform articulation has been described as an atavistic trait of human foot morphology, and it is commonly proposed as a relative risk factor for development of the hallux abductovalgus (HAV) deformity. The objectives of this investigation were to 1) provide descriptive normative radiographic data on a series of first metatarsal-medial cuneiform articulations and 2) correlate these findings to other common radiographic parameters used to define the HAV deformity. We measured radiographic parameters including the first intermetatarsal angle, hallux abductus angle, tibial sesamoid position, Engel's angle, and 2 measures of obliquity in the transverse and sagittal planes on a consecutive series of 136 weightbearing foot radiographic projections from subjects without a history of foot/ankle surgery or fracture/dislocation. Measurements were considered as continuous variables, graphically depicted against each other on frequency scatter plots, and analyzed by means of Pearson correlation coefficients. Only 1 bivariate comparison demonstrated a weak negative correlation (Engel's angle versus Obliquity_1 [Pearson -0.259; p = .002]). The results of this investigation did not demonstrate a statistically significant or clinically substantial relationship between the obliquity of the first metatarsal-cuneiform joint and common radiograph parameters of the HAV deformity. Although not specifically studied here, these results might potentially indicate function, as opposed to structure, in the developmental pathogenesis of the HAV deformity.

Soft Tissue Reconstruction with Diabetic Foot Tissue Loss

Although substantial advances have been made in treatment of diabetic foot disease with respect to patient education, preventative measures, early intervention, and prophylactic procedures, most surgical interventions for this condition are reactionary. Patients still primarily present to emergency departments with acute infections and tissue necrosis. The surgical intervention for this results in soft tissue deficit, often with partial foot amputation, through excisional debridement of pathologic tissue. Minimizing this initial soft tissue loss, with subsequent reconstruction of the defect, forms the focus of this article with a detailed anatomic assessment of structures at risk in the forefoot, midfoot and rearfoot.

A Review of the Effect of Lower-Extremity Pathology on Automobile Driving Function

The effect of lower-extremity pathology and surgical intervention on automobile driving function has been a topic of contemporary interest in the medical literature. The objective of this review was to summarize the topic of driving function in the setting of lower-extremity impairment. Included studies involved lower-extremity immobilization devices, elective and traumatic lower-limb surgery, chronic musculoskeletal pathology, and diabetes as it relates to the foot and ankle, focusing on the effect each may have on driving function. We also discuss the basic US state regulations with respect to impaired driving and changes to automobile structure that can be made in the setting of lower-extremity pathology.

Early Weightbearing After Arthrodesis of the First Metatarsal-Medial Cuneiform Joint: A Systematic Review of the Incidence of Nonunion

Arthrodesis of the first metatarsal-medial cuneiform articulation is a reliable and effective surgery for correction of hallux abducto valgus deformity. However, one potential relative contraindication to the procedure is the extended period of non-weightbearing immobilization that is typically associated with the postoperative course. The objective of this investigation was to perform a systematic review of the incidence of nonunion after early weightbearing in patients who underwent arthrodesis of the first metatarsal-medial cuneiform articulation for correction of a hallux abducto valgus deformity. We performed a review of electronic databases with the inclusion criteria of retrospective case series, retrospective clinical cohort analyses, and prospective clinical trials with 15 or more participants; a mean follow-up period ≥12 months; a postoperative early weightbearing protocol (defined as ≤2 weeks); a clear description of the fixation construct; and a reported incidence rate of nonunion. Eight studies met our inclusion criteria, with a total of 443 arthrodeses analyzed. Of these, 16 (3.61%) were described as developing a nonunion. This would likely be considered an acceptable rate of nonunion when considering this procedure and might indicate that the Lapidus procedure does not always require an extended period of postoperative non-weightbearing immobilization.

Level of Agreement With a Multi-Test Approach to the Diagnosis of Diabetic Foot Osteomyelitis

Although bone biopsy has historically been considered the "gold standard" or "standard reference" for the diagnosis of diabetic foot osteomyelitis, some contemporary investigations have provided evidence against this as a single diagnostic test and in support of a combination of clinical, laboratory, and radiographic findings. The objective of this investigation was to measure the level of agreement between several commonly used forms of diagnostic testing for diabetic foot osteomyelitis. A retrospective chart review was performed of 50 consecutive patients admitted to a single tertiary healthcare center with the documented performance of 1) a clinical probe-to-bone test on hospital admission; 2) plain film radiographs prior to any surgical intervention; 3) magnetic resonance imaging prior to any surgical intervention; and an intraoperative excisional bone debridement performed, with samples sent for both 4) histologic analysis and 5) microbiologic analysis. A frequency count of agreement among these 5 tests was performed, and the interobserver (or inter-test) agreement was measured using the kappa statistic. We observed low levels of inter-test agreement between the 5 diagnostic tests (range 42.0%-62.0%), and levels of chance-corrected agreement were well below what would be considered appropriate for a "gold standard" or "standard reference." Levels of the kappa statistic ranged from 0.0 to 0.220, with most inter-test comparisons falling in the "poor agreement" and "slight agreement" interpretation ranges. The highest level of agreement occurred between the plain film radiographs and magnetic resonance imaging (62.0% agreement and kappa statistic of 0.220). Although it is likely that a combination of clinical, radiographic, and laboratory tests provides the best diagnostic approach for diabetic foot osteomyelitis, the data provided herein indicate that the tests themselves might have high intrinsic levels of unreliability and that the specific combination of tests that might be best used remains unclear.

Reliability, Surgeon Preferences, and Eye-Tracking Assessment of the Stress Examination of the Ankle Syndesmosis

The diagnosis and stabilization of ankle syndesmotic injuries after acute injury remains an area of controversy in the foot and ankle surgical literature, seemingly without universal consensus. The primary objective of this investigation was to determine the frequency of agreement and reliability of the stress examination of the ankle syndesmosis. Secondary objectives were to determine surgeon preferences and protocols with respect to the ankle syndesmosis and to use gaze recognition software to perform an eye-tracking assessment during performance of stress examinations. Twelve foot and ankle surgeons, 12 residents, and 12 students were shown 5 intraoperative fluoroscopic still images and videos of the stress examination of the ankle syndesmosis. They were asked to evaluate the result as being "positive" or "negative" for syndesmotic stability. The overall reliability of the interpretation of the stress examination of the ankle syndesmosis was a kappa of 0.123 (surgeons 0.087; residents 0.019; students 0.237), indicating "slight" agreement. Survey results indicated wide variability in the perioperative preferences and protocols of surgeons dealing with the evaluation and treatment of the ankle syndesmosis. Eye-tracking results also demonstrated variability in the anatomic structures of interest focused on during performance of this testing. The results of this investigation provide evidence of reliability well below what would be expected of a gold standard test during stress examination of the ankle syndesmosis. These results indicate that future scientific endeavors are required to standardize the performance and interpretation of this testing.

Evaluation of the Mechanical Axis of the First Ray Before and After First Metatarsal-Phalangeal Joint Reconstructive Surgery

LaPorta et al published a description of measurement of the mechanical axis of the first ray in an attempt to introduce center-of-rotation angulation principles into forefoot reconstructive surgery. They found significant differences in the measurement of the first intermetatarsal angle between groups of feet with and without hallux abducto valgus deformity, but they found no difference in the measurement of the M1-M2 mechanical axis angle between groups. The objectives of this study were to further investigate the proposed M1-M2 mechanical axis angle and to examine the effect of hallux abducto valgus corrective surgery on its measurement. We retrospectively evaluated weight-bearing dorsal-plantar projection radiographs taken in the angle and base of gait of 56 consecutive feet before and after first metatarsal-phalangeal joint corrective surgery. On each radiograph, we calculated the first intermetatarsal angle, the hallux abductus angle, the tibial sesamoid position, the M1-M2 mechanical axis angle, and the position of the sesamoids relative to the mechanical axis of the medial column. Statistically significant decreases were observed when comparing pre- versus post-operative measurement of the first intermetatarsal angle (-4.83°; p < .001), hallux abductus angle (-11.46°; p < .001), and tibial sesamoid position (-1.99 positional grade; p < .001). Statistically significant differences were also observed for the M1-M2 mechanical axis angle (-0.47°; p = .007) and the position of the sesamoids relative to the mechanical axis of the medial column (0.38 positional grade; p < .001), but it is unlikely that these results would be considered clinically significant given the differences of less than 1° and less than 1 positional grade, respectfully. The results of this investigation add to the body of knowledge and will hopefully lead to future investigations into the progression, evaluation, and treatment of the hallux abducto valgus deformity.

Anatomic Feasibility of Distal Fibula Bicortical Screw Fixation With Lateral Neutralization Plating for Rotational Ankle Fractures

A common technique for fixation of rotational fibular fractures is to use an interfragmentary compression screw with a laterally positioned neutralization plate. The objective of the present investigation was to examine the anatomic feasibility of distal fibula bicortical fixation within this plating technique. A specific screw insertion technique was performed through a laterally positioned one-third tubular plate on a consecutive series of 81 intact cadaveric ankle mortises. The most distal plate hole was drilled, aimed 10° posterior to the midline of the fibula. The second-most distal plate hole was drilled, aimed 25° superiorly. The specimens were then dissected, and the screw termini were physically examined for whether they had penetrated the articular cartilage of the ankle mortise. The length of the most distal bicortical screw measured a mean ± standard deviation of 20.44 ± 2.49 (range 14 to 26) mm, with an extra-articular terminus in 95.06% of specimens. The length of the second-most distal bicortical screw measured a mean ± standard deviation of 19.68 ± 3.02 (range 12 to 28) mm, with an extra-articular terminus in 100% of the specimens. The results of the present study provide evidence that bicortical distal fibular fixation in accordance with basic fixation principles is anatomically possible and feasible with a one-third tubular plate. This could potentially obviate the need for more expensive fixation options (i.e., locked plates or anatomically contoured plates) and fixation options that are biomechanically stable but potentially anatomically impeding (i.e., posterior antiglide plating).

Anatomic Limitations of the Transmetatarsal Amputation With Consideration of the Deep Plantar Perforating Branch of the Dorsalis Pedis Artery

The transmetatarsal amputation is considered a durable procedure with respect to limb salvage when managing the consequences of diabetic foot disease. The success of the procedure is, in part, determined by the preoperative appreciation of arterial and functional status. The objectives of the present investigation were to determine the length of the remaining first metatarsal required during transmetatarsal amputation to preserve the anastomotic connection of the deep plantar perforating artery and subsequent "vascular arch" of the foot and the insertion of the tibialis anterior tendon. The primary outcome measure of our investigation was a measurement of the distance between the first metatarsal-medial cuneiform articulation and the distal extent of the deep plantar perforating artery in 85 embalmed lower limbs. As a secondary outcome measure, the insertion of the tibialis anterior tendon was evaluated relative to the deep plantar perforating artery. The most distal extent of the deep plantar perforating artery was observed at a mean ± standard deviation of 15.62 ± 3.74 (range 6.0 to 28.28) mm from the first metatarsal-medial cuneiform articulation. Most (89.41%) of the arteries were found within 20 mm of the first metatarsal-medial cuneiform articulation. The insertion of the tibialis anterior tendon was found to be proximal to the deep plantar perforating artery in all specimens (100.0%). In conclusion, 2.0 cm of remnant first metatarsal might represent an anatomic definition of how "short" a transmetatarsal amputation can safely be performed in most patients when considering the vascular and biomechanical anatomy.