Benjamin R. Williams

New radiographic parameters assessing forefoot abduction in the adult acquired flatfoot deformity.

Background: Stage II flatfoot secondary to posterior tibial tendon insufficiency may be subclassified into mild (IIa) and severe (IIb) deformity based on the degree of talonavicular abduction. Current assessment of this abduction is difficult. We hypothesized that two new anteroposterior radiographic parameters, the lateral talonavicular incongruency angle (IA) and incongruency distance (ID) would demonstrate good reliability, correlate with current abduction parameters, and differ in IIb deformity, IIa deformity, and controls. Materials and Methods: Preoperative radiographs for consecutive patients undergoing flatfoot reconstruction were reviewed and subdivided into those with a Stage IIb (n = 32) or Stage IIa (n = 8) deformity. A third group of patients without flatfoot served as control (n = 30). Radiographs were measured blindly by two investigators. Reliability was assessed with intraclass correlation coefficients (ICC), correlation with existing parameters with Pearson coefficients, and comparison between groups with analysis of variance. Results: The mean intrarater and interrater ICCs for the IA (0.88 and 0.81, respectively) were high. The IA correlated well with the coverage angle (r = 0.86) and uncoverage percent (r = 0.76). The IA was higher in the IIb versus IIa patients (p = 0.007) and in the IIb group versus control (p < 0.001). The ID demonstrated excellent reliability (ICCs of 0.83 and 0.83), but correlated poorly with the two other abduction parameters (r = −0.59 and −0.49) and failed to differentiate between the three groups (p = 0.0528). Conclusion: This data suggests that the IA is reliable and may help subclassify Stage II flatfoot deformity. Level of Evidence: III, Retrospective Comparative Study

Deltoid Ligament Reconstruction with Peroneus Longus Autograft in Flatfoot Deformity

Background: Stage IV posterior tibial tendon insufficiency is characterized by the presence of valgus talar tilt in the setting of a flatfoot deformity which results from attenuation of the deltoid ligament. Correcting valgus tilt at the time of flatfoot reconstruction may prevent future collapse and the need for joint sacrificing procedures. The purpose of this study was to report the intermediate-term results of patients who underwent deltoid ligament reconstruction using a peroneus longus tendon transfer. Materials and Methods: Five patients (mean age, 67 years ± 5.3 years) who underwent flatfoot reconstruction along with deltoid ligament reconstruction using a peroneus longus autograft were evaluated at a mean of 8.9 ± 1.7 years after surgery. The FAOS, SF-36v2, and VAS surveys were administered. The correction of valgus talar tilt was determined with weightbearing radiographs of the ankle. Ankle range of motion along with standing hindfoot alignment was assessed. Results: The postoperative average FAOS and SF-36v2 were 68.3 (range, 55.2 to 85.0) and 75.7 (range, 40 to 92), respectively. The valgus talar tilt improved from 7.7 degrees preoperatively to 2.1 degrees postoperatively. Mean ankle range of motion was 47 degrees (range, 40 degrees to 55 degrees). Mean hindfoot alignment was 4 degrees valgus (range, 1 degree varus to 8 degrees valgus). Conclusion: Deltoid ligament reconstruction using a peroneus longus tendon transfer was a useful technique for reducing tibiotalar tilt in the setting of stage IV flatfoot deformity. Correction and function were maintained at intermediate-term followup. Level of Evidence: IV, Retrospective Case Series

Surgical Management of Hallux Rigidus

Abstract Hallux rigidus is the most common degenerative joint pathology of the foot. Untreated, it may result in notable limitations in gait, activity level, and daily function. Positive outcomes can be achieved with nonsurgical management; surgery is recommended for the sufficiently symptomatic patient for whom nonsurgical measures are unsuccessful. Surgery is selected based on grade of involvement. Early to mid‐stage hallux rigidus is best managed with cheilectomy or cheilectomy and proximal phalanx osteotomy. Arthrodesis and arthroplasty are reserved for late‐stage hallux rigidus.

Incidence of plantar lateral foot pain before and after the use of trial metal wedges in lateral column lengthening.

Background: One of the major concerns with lateral column lengthening (LCL) in symptomatic flatfoot deformity treatment is the risk of postoperative plantar lateral foot discomfort. We evaluated whether this risk can be minimized by using trial metal wedges. Using our studys evaluation tools, the incidence of postoperative plantar lateral foot discomfort before and after using trial metal wedges was determined. Materials and Methods: The incidence of plantar lateral foot pain after LCL was retrospectively assessed in 122 consecutive patients (132 feet) after they had undergone flatfoot reconstruction with LCL between 2001 and 2007. To determine if the incidence could be reduced, levels of pain or revision were compared before and after the use of trial metal wedges. The ratio of wedge size to preoperative radiographic calcaneal length was also determined. Results: The overall incidence of plantar lateral discomfort was 11.2%. The incidence of pain or revision was lower after the introduction of trial metal wedges (6.3% compared to 14.7%), but did not reach significance (p = 0.084). There was no significant difference found in the ratio of the size of bone graft wedge to calcaneal length between the two groups (p = 0.805). Conclusion: The incidence of plantar lateral foot discomfort overall was 11.2% after LCL. We believe this risk may be reduced using trial metal wedges, properly judging eversion stiffness and carefully assessing the position of the foot intraoperatively. Level of Evidence: III, Retrospective Comparative Study

Cerebral Vascular Accident in a Patient With Reactive Thrombocytosis : A Rare Cause of Stroke

Background and Purpose:Reactive thrombocytosis (RT) is usually a benign process and is not associated with thrombotic or hemorrhagic events Summary of Case:We report a case of a young man who suffers a stroke caused by RT, which was secondary to splenectomy, iron deficiency, and infection. Conclusions:Although rarely documented, RT can be the cause of a major vascular event.

Publications Rates for Podium and Poster Presentations From the American Orthopaedic Foot & Ankle Society: 2008-2012:

Background: National orthopaedic meetings are used to disseminate current research through podium and poster abstract presentations. Not all of these abstracts go on to full-text journal publication. The purpose of this study was to determine the publication rates of podium and poster presentations from the American Orthopaedic Foot & Ankle Society (AOFAS) annual meetings between 2008 and 2012. Methods: All accepted podium and poster abstracts from the 2008-2012 AOFAS annual meetings were compiled from the AOFAS office, Physician Resource Center website, and hardcopy meeting programs. PubMed and Google Scholar searches were performed for journal publications using key words in the presentation abstracts and authors’ names. Full-text journal publication rates for the presentations were calculated per year, as were the most common journals of publication. Results: Overall full-text publication rate was 73.7% for podium presentations and 55.8% for posters. Podium presentations were published in a journal significantly more often than posters (P < .0001; odds ratio 2.17 [95% confidence interval (CI), 1.64-2.86]). The mean time to publication was 1.5 and 1.4 years for podium and poster presentations, respectively (P = .124). The most common journal for podium and poster publications was Foot & Ankle International. Conclusion: Podium abstracts were significantly more likely to be published compared to posters. The AOFAS overall full-text journal publication rate was one of the higher reported rates compared with other national orthopedic society meetings, which have ranged from 34% to 73%.

Vitamin D Levels Do Not Predict Risk of Metatarsal Fractures

Introduction. In the literature, there is conflicting data regarding the relationship between vitamin D and fractures. Reports on the effects of vitamin D levels on pathologies of the foot and ankle are limited. The purpose of this study is to assess the prevalence of vitamin D insufficiency in patients who have sustained low-energy metatarsal fractures compared to foot or ankle sprains without osseous involvement. Methods. Between May 2012 and August 2014, vitamin D levels and demographic data were collected prospectively in a total of 99 patients; 71 with metatarsal fractures and 28 with sprains, both from a low-energy mechanism of injury. Data between the metatarsal fracture group and sprain group were compared through univariate and multivariate analyses. Results. Mean vitamin D in the fracture group was 26.9 ng/mL (range = 78.0-4.3), and in the sprain group it was 27.1 ng/mL (range = 64.1-8.3; P = .93). Vitamin D insufficiency (<30 ng/mL) was present in 47 (66%) of fracture patients and 20 (71%) of sprain patients (P = .81). Conclusion. A high incidence of hypovitaminosis D was seen in all foot and ankle patients. There was no difference in mean vitamin D level or incidence of vitamin D insufficiency between patients with metatarsal fractures or sprains resulting from similar low-energy mechanisms. Levels of Evidence: Level III: Prospective, case-control study

Functional Outcomes of Symptomatic Implant Removal Following Ankle Fracture Open Reduction and Internal Fixation

Background: Orthopedic implant removal following open reduction internal fixation of a fracture is a common procedure, especially in the foot and ankle. The purpose of this study was to evaluate functional change after the removal of symptomatic implants following ankle fracture open reduction internal fixation (ORIF) using the Short Musculoskeletal Function Assessment (SMFA) outcome score. We hypothesized that implant removal after ankle fracture would result in improved functional outcomes. Methods: Retrospective review of prospectively collected data on patients with a closed ankle fracture between 2013 and 2016 was performed. Inclusion criteria were skeletal maturity, symptomatic ankle implants and completion of the SMFA questionnaire prior to and 6 months after removal. Exclusion criteria were development of a nonunion, prior or current infection, peripheral neuropathy or ongoing litigation surrounding the surgery. The primary outcome was change in SMFA score from baseline to follow-up using Wilcoxon signed-rank test. Additional logistic regression models evaluated the effects of age, sex, body mass index, smoking status, and patient American Society of Anesthesiologists scores. Results: The study population consisted of 43 patients. There was a statistically significant improvement in function, represented by a decrease in SMFA scores from baseline to the 6-month follow-up period (∆ = −4.1 [95% confidence interval, −7.0, −1.3]; P = .003). Secondary outcome measures of the bother index and daily activities domain also demonstrated significant improvements (P = .005 and P = .002, respectively). Additional logistical regression models identified no significant effects by assessed covariates for change in SMFA scores. Conclusion: Patients with symptomatic implants following ankle fracture ORIF had a statistically significant improvement in function following implant removal. There appears to be value in removing implants from the ankle in patients who report discomfort during daily activities. Further investigation into the specific indications for implant removal and the impact of injury and fracture pattern on outcomes is warranted. Level of Evidence: Level IV, case series.

Intra-articular Hematoma Block Compared to Procedural Sedation for Closed Reduction of Ankle Fractures:

Background: Initial treatment for a displaced ankle fracture is closed reduction and splinting. This is typically performed in conjunction with either an intra-articular hematoma block (IAHB) or procedural sedation (PS) to assist with pain control. The purpose of this study was to compare the safety of IAHB to PS and evaluate the efficiency and efficacy for each method. Methods: A retrospective chart review for ankle fractures requiring manipulation was performed for patients seen in a level I trauma center from 2005 to 2016. The primary outcome was rate of successful reduction. Several secondary outcome measures were defined: reduction attempts, time until successful reduction, time spent in the emergency department (ED), rate of hospital admission, and adverse events. The analysis included 221 patients who received IAHB and 114 patients who received PS. Results: The demographics between the 2 groups were similar, with the exception that more patients with a dislocation received PS, which prompted a subgroup analysis. This analysis demonstrated that patients with an ankle fracture and associated tibiotalar joint subluxation underwent closed reduction in a shorter period of time with the use of an IAHB compared with those receiving PS. In patients sustaining a tibiotalar fracture dislocation, patients receiving PS were successfully reduced with 1 reduction attempt more frequently than those receiving IAHB. Orthopedic surgeons also had higher rates of success on first attempt compared with ED providers. Conclusion: Both IAHB and PS were excellent options for analgesia that resulted in high rates of successful closed reduction of ankle fractures with adequate safety. IAHB can be considered a first-line agent for patients with an ankle fracture and associated joint subluxation. Level of Evidence: Level III, retrospective comparative series.

The pursuit of scholarship: Why we should care about resident research

Research is a foundational component of an orthopaedic residency. It fosters intellectual curiosity and pursuit of excellence, while teaching discipline and the scientific method. These are the key principles for careers in both community-based practice and academia. Currently, no consensus exists on how to best engage residents and support their research endeavors. In 2014, the American Academy of Orthopaedic Surgeons Board of Specialty Societies Research and Quality Committee convened a Clinician-Scientist Collaboration Workgroup. The workgroups task was to identify barriers to clinical and basic science research, and to propose feasible recommendations to overcome these barriers. Herein, we have compiled the opinions of various stakeholder constituencies on how to foster scholarly pursuits during an orthopaedic residency. These opinions reflect the workgroups conclusions that research is directly and indirectly influenced by funding, departmental support, and mentorship, and that early exposure and dedicated time to pursue scholarly activities may have a positive impact on lifelong research interests.