Metatarsal shortening via oblique osteotomy

Abstracts from the 6th IFFAS Triennial Meeting / Foot and Ankle Surgery 23(S1) (2017) 29–154

Methods: Seven sets of cadaver lower extremities were studied. One limb underwent single medial incision DHA while the other underwent two-incision DHA. Stress radiographs were obtained following debridement. The extent of debridement was calculated by computer mapping of the joint surfaces. Student t-tests were used to compare techniques. Results: The percentage of cartilage debrided at the calcaneal posterior facet, the posterior surface of the talus at the subtalar joint, and the talar head were significantly different. There were no differences, however, in percent debrided at the calcaneal middle facet, the middle surface of the talus at the subtalar joint, or the navicular. In the single incision group, 5/7 specimens had radiographic evidence of medial talar tilt compared to 1/7 in the two-incision group. Conclusion: There was significantly less cartilage debrided from the posterior facet of the calcaneus, the posterior surface of the talus at the subtalar joint, and the talar head in the single incision approach. Additionally, more specimens had radiographic evidence of medial talar tilt (deltoid insufficiency) in the single-incision group compared to in the two-incision group. http://dx.doi.org/10.1016/j.fas.2017.07.468

380 Anatomic versus non-anatomic reconstruction for chronic lateral ankle ligament instability S.S.H. Park 1,∗ , C. Sermer 1 , J. Lau 2 , C. Kim 1 , A. Veljkovic 3 1 University of Toronto, Division of Orthopaedic Surgery, Canada 2 University Health Network, Toronto Western Hospital, Division of Orthopaedic Surgery, Canada 3 University of British Columbia, St. Paul’s Hospital, Department of Orthopaedic Surgery, Canada

Introduction: This study aimed to meta-analyze the literature to compare clinical outcomes following anatomic versus nonanatomic lateral ankle ligament reconstructions. Methods: Computerized search of multiple electronic databases was conducted for studies involving anatomic/non-anatomic reconstructions for chronic lateral ankle ligament instability. Included were English-language publications with minimum 2-year follow-up. Excluded were studies involving concomitant medial ankle instability, ankle/hindfoot fractures, previous ankle/hindfoot surgery, skeletal immaturity, and biomechanical studies. Clinical outcomes were evaluated using the Good rating scale, Karlsson–Peterson score, Foot and Ankle Outcome Score (FAOS), AOFAS Ankle/Hindfoot score, anterior drawer, talar tilt, and range of motion. Secondary outcomes included complications due to failure (re-rupture/instability/re-operation), infection, neurologic injury, and subsequent arthritis. For each outcome measure, a combined weighted effect size was calculated using random effects modeling. Effect size difference between groups was tested by chisquare test (for proportions) or t-test (for means). Results: Ninety-five publications met study criteria. A total of 3936 ankles (2561 anatomic and 1375 non-anatomic) were analyzed. Anatomic reconstructions had higher proportion of excellent/good outcomes on the Good scale (0.89 versus 0.76, p < 0.0001) and higher mean Karlsson–Peterson scores (90.3 versus 81.6, p = 0.006), while resulting in lower rates of failure (0.03 versus 0.06, p < 0.0001), neurologic injury (0.012 versus 0.119, p < 0.001), and osteoarthritis (0.10 versus 0.20, p < 0.0001), when compared to non-anatomic reconstructions. There were no differences in AOFAS

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score, talar tilt, anterior drawer, and infection rates, with insufficient data to compare the FAOS scores and range of motion. Conclusions: Anatomic reconstructions for chronic lateral ankle instability provide superior subjective outcomes and lower complication rates than non-anatomic techniques. http://dx.doi.org/10.1016/j.fas.2017.07.469

381 When are patients satisfied? Correlation of PROMIS values with patient acceptable symptom state M. Anderson 1,∗ , J. Houck 2 , B. DiGiovanni 1 , A.S. Flemister 1 , J. Ketz 1 , J. Baumhauer 1 1 2

University of Rochester, United States George Fox University, United States

Background: PROMIS values are being adopted due to ease and influence on clinical decisions while Patient Acceptable Symptom State (PASS) is an outcome measure used in other areas of medicine that captures when patient’s symptoms reach an acceptable level. Aims: (1) Association of PROMIS scales with a PASS rating, (2) threshold values of PROMIS function (PF), pain (PI), depression (D) associated with PASS rating, and (3) whether PROMIS, and patient demographics are predictive of a PASS rating. Methods: Foot and ankle patients over 4 weeks prospectively completed PROMIS PF, PI and D as well as the validated PASS question. The analysis included a two-way ANOVA to compare PROMIS scores between patients grouped as PASS (Yes) and PASS (No); ROC analysis to determine AUC, cut offs, and 95% sensitivity/specificity for PASS; Logistic regression analysis with PROMIS, age, gender, and visit type as predictors of PASS (Yes)/(No). Results: PROMIS PF was lower and PI higher, however, PROMIS D was similar between PASS (Yes/No) groups. The cut offs for PASS (Yes) were 52.0 and 50.7 for PF and PI. The cut offs for PASS (No) were 23.6 and 69.6 for PF and PI. Regression analysis showed that gender, visit type, and PROMIS (PI/PF) significantly predicted PASS (Yes)/(No). Discussion: PROMIS t-scores of near 50 (average of US population) correspond to PASS (Yes), and may be a reasonable goal for patient outcome. For patients that are PASS ambiguous, other factors such as preoperative PROMIS scores (PF and PI), gender, and visit type (new or follow up) may motivate discussions with patients about their expectations of treatment. http://dx.doi.org/10.1016/j.fas.2017.07.470

382 Metatarsal shortening via oblique osteotomy M. Anderson 1,∗ , J. Houck 2 , A.S. Flemister 1 , I. Oh 1 , J. Baumhauer 1 1 2

University of Rochester, United States George Fox University, United States

Background: Metatarsal shortening can be accomplished with either Weil osteotomy or via shortening through the shaft. Each procedure has challenges; the Weil osteotomy is prone to cock up deformity of the toe, while the shaft osteotomy is plagued by nonunion and technical difficulty. Aims: The purpose of this study was to evaluate the union rate and outcomes of patients undergoing metatarsal shaft osteotomy with a shortening plate designed for the procedure.

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Abstracts from the 6th IFFAS Triennial Meeting / Foot and Ankle Surgery 23(S1) (2017) 29–154

Methods: We reviewed the charts of 22 patients who underwent 28 metatarsal shaft shortening osteotomies utilizing a specially designed plate that allows for 1–6 mm of shortening. Preand post-operative PROMIS scores were collected for all patients and a t-test was performed to determine significant change in tscores from pre-op to post-op. Furthermore, charts we reviewed for secondary surgery related to non-union, malunion or other hardware related complication. Result: Mean follow up was 225 days. No patients experienced non-union or required additional surgery for malunion or hardware prominence. PROMIS Pain Interference (PI) significantly improved, however PROMIS Physical Function (PF) were not significantly improved at follow up. Conclusion: We report a high union rate of oblique metatarsal shaft shortening osteotomies using a specially designed plate. PROMIS is an assessment of global health and it is possible that the role the toes in overall health isn’t significant enough to be captured. Never the less, the majority of patients did experience improvement in pain. Oblique metatarsal shaft shortening osteotomy using a specially designed plate demonstrated clinical safety and improvement in pain outcomes. http://dx.doi.org/10.1016/j.fas.2017.07.471

383 Arthroscopic debridement for advanced haemophilic ankle arthropathy T. Yasui 1,∗ , J. Hirose 2 , K. Ono 3 , S. Nakamura 1 , H. Takedani 3 1

Teikyo University Mizonokuchi Hospital, Japan The University of Tokyo Hospital, Japan 3 Research Hospital, The Institute of Medical Science, The University of Tokyo, Japan 2

Introduction: In patients with haemophilia, intra-articular haemorrhage often occurs repetitively, which leads to proliferation of an easily bleeding synovium and joint destruction. When severe joint destruction has occurred in the ankle, arthrodesis or arthroplasty is usually considered. However, most patients are young and it annoys surgeons. We recently employed arthroscopic ankle debridement for such patients. We herein report the short-term results. Methods: We reviewed eight consecutive patients who underwent arthroscopic debridement for advanced haemophilic ankle arthropathy and were followed up for >6 months (range, 6–16 months). All patients had severe haemophilia. The mean age was 29 years. In the operation, the hypertrophic synovium and avulsed cartilage was arthroscopically resected. Postoperatively, the patients were allowed to bear weight as tolerated. Results: No complications occurred including uncontrolled bleeding. The range of motion improved in all but one patient. In all five patients for whom the Japanese Society for Surgery of the Foot scale was obtained, its score improved (mean, 64 preoperatively to 81 at last follow-up). In all five patients for whom pain scale was recorded, the pain was markedly reduced (mean numeric rating scale, 5.7 preoperatively to 2.2 at last follow-up). Conclusions: We performed arthroscopic debridement for patients with advanced haemophilic ankle arthropathy and achieved favourable short-term results. Surgical mass reduction of easily bleeding synovial tissues, washing out of chemical mediators, and removal of free chondral particles should be beneficial.

We believe that arthroscopic ankle debridement is worth trying to avoid or at least delay arthrodesis or arthroplasty. http://dx.doi.org/10.1016/j.fas.2017.07.472

384 The reliability of computed tomography in the assessment of ankle fusion N. Yeo 1,3,∗ , F. Waly 1,3 , A. Veljkovic 1,3 , P. Salat 2,3 , M. Glazebrook 1,2,3 , K. Wing 1,3 , M. Penner 1,3 , A. Younger 1,3 1 St. Paul’s Hospital, University of British Columbia, Vancouver, Canada 2 Rockyview Hospital, University of Calgary, Canada 3 Queen Elizabeth II Health Science Centre, Dalhousie University, Halifax, Canada

Introduction: Determining the status of bony fusion following surgery can be challenging and has implications on clinical decision making. Computed Tomography (CT) is increasingly being used as the modality of choice. We describe a standardized technique for measuring percentage fusion of the ankle joint on CT, determined the inter and intra-rater reliability of this technique and evaluated the association between percentage fusion and functional outcome. Methods: Twenty patients who underwent isolated ankle fusions were retrospectively studied. A CT scan was performed at 24 weeks post-surgery. Five blinded foot and ankle surgeons evaluated these scans twice. Each coronal and sagittal image was measured for percentage fusion using a standardized protocol. The ankle osteoarthritis scale (AOS) was recorded at 24 weeks. Inter and intra-rater reliability was calculated using intra-class correlation. Linear regression model was fitted to examine the association between percentage fusion and AOS. Results: The inter-rater reliability was 0.98 (sagittal) (95% CI 0.96, 0.99) and 0.93 (coronal) (95% CI 0.85, 0.97). The intra-rater reliability was 0.98 (sagittal) (95% CI 0.95, 0.99) and 0.95 (coronal) (95% CI 0.89, 0.98). Percentage fusion had a significant association with AOS at 24 weeks post-surgery (p = 0.01). Conclusions: We conclude that percentage fusion in the ankle joint can be reliably measured on CT scan using either coronal or sagittal views. The authors believe that future studies comparing fusion techniques or bone graft substitutes should use this technique as the primary outcome measure. Fusion is also not a binary measure but has a gradation that affects clinical outcome. http://dx.doi.org/10.1016/j.fas.2017.07.473