Publications by authors named "Bart Lubberts"

49 Publications

The Effects of Chronic Ankle Instability on the Biomechanics of the Uninjured, Contralateral Ankle During Gait.

Orthop Surg 2022 Jul 19. Epub 2022 Jul 19.

Foot & Ankle Research and Innovation Laboratory (FARIL), Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.

Objective: To determine whether unilateral chronic ankle instability (CAI) affects the kinematics of the uninjured contralateral ankle.

Methods: In this case-control study, 15 adult patients with unilateral CAI and 15 healthy controls were studied. Both the unstable and uninjured ankles in patients with unilateral CAI (CAI group, n = 15) were compared with that of healthy individuals (control group, n = 15). Applying body photo-reflective markers, the participant's motion during gait was measured. Biomechanical variables including overall ankle-toe angle, linear velocity, linear acceleration, angular velocity, angular acceleration, range of motion (RoM) in dorsiplantar flexion, and inversion-eversion at initial contact, loading response, mid-stance, terminal stance, pre-swing, and swing phase of the gait were measured.

Results: In patients with CAI, the injured and uninjured ankles were significantly different regarding angle-toe angle, inversion-eversion RoM, dorsiplantar flexion in mid-stance, inversion-eversion at initial contact and terminal stance as well as the pre-swing and swing phases (p < 0.01). The uninjured ankles of patients showed lower ankle-toe velocity (p = 0.01) and acceleration (p = 0.01) compared to both the left and right ankles of the controls. In addition, the uninjured ankles of the patients showed decreased ankle dorsiflexion and increased inversion during initial contact, loading response, mid-stance, terminal stance, pre-swing, and swing compared to the control group (p < 0.017).

Conclusion: The results suggest that unilateral CAI can affect gait biomechanics in the contralateral uninjured ankle. Left unaddressed, unilateral CAI may lead to increased morbidity to the contralateral uninjured side. When surgery is not preferred for the management of unilateral CAI, rehabilitation protocols should focus on both sides.
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http://dx.doi.org/10.1111/os.13307DOI Listing
July 2022

Use of a Lightweight Portable Fluoroscopy Device for Obtaining Weightbearing Ankle Images.

J Foot Ankle Surg 2022 May 18. Epub 2022 May 18.

Foot & Ankle Research and Innovation Laboratory (FARIL), Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Foot and Ankle Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA.

Portable fluoroscopy devices provide point-of-care imaging in emergency and out-patient clinics. In this prospective study, we compared weightbearing images of syndesmosis obtained using a novel lightweight portable battery-powered fluoroscopy device with those obtained with a conventional radiography device. Eleven healthy participants underwent bilateral 3-view weightbearing imaging of both ankles using a radiography (X-ray group) device and a portable fluoroscopy system (LPF group). Anteroposterior, mortise, and lateral views were compared between the 2 techniques. Radiographic measurements were done by 2 observers. These measurements included talar tilt, tibiofibular clear space, tibiofibular overlap, plafond malleolar angle, medial distal tibial angle, medial clear space, lateral distal tibial angle, anterior and posterior tibiofibular distance were measured using the appropriate view. Data were compared between the 2 techniques; the interobserver agreement was calculated within each group. P < .05 was considered statistically significant. Comparing the 2 imaging modalities, there was no significant difference between the measurements in LPF and X-ray groups except plafond malleolar angle. The overall interobserver agreement was excellent between the 2 observers. There was no significant difference between the measures by the 2 observers and between the bilateral ankles. Fluoroscopy was associated with about 50% extra radiation exposure, although the absolute amount of radiation was not clinically significant. These results support the use of weightbearing images using portable fluoroscopy device as an alternative for the conventional radiography systems.
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http://dx.doi.org/10.1053/j.jfas.2022.05.006DOI Listing
May 2022

Detection of ankle fractures using deep learning algorithms.

Foot Ankle Surg 2022 May 26. Epub 2022 May 26.

Foot & Ankle Research and Innovation Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston 02114, MA, USA; Foot & Ankle Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston 02114, MA, USA. Electronic address:

Background: Early and accurate detection of ankle fractures are crucial for optimizing treatment and thus reducing future complications. Radiographs are the most abundant imaging techniques for assessing fractures. Deep learning (DL) methods, through adequately trained deep convolutional neural networks (DCNNs), have been previously shown to faster and accurately analyze radiographic images without human intervention. Herein, we aimed to assess the performance of two different DCNNs in detecting ankle fractures using radiographs compared to the ground truth.

Methods: In this retrospective case-control study, our DCNNs were trained using radiographs obtained from 1050 patients with ankle fracture and the same number of individuals with otherwise healthy ankles. Inception V3 and Renet-50 pretrained models were used in our algorithms. Danis-Weber classification method was used. Out of 1050, 72 individuals were labeled as occult fractures as they were not detected in the primary radiographic assessment. Single-view (anteroposterior) radiographs was compared with 3-views (anteroposterior, mortise, lateral) for training the DCNNs.

Results: Our DCNNs showed a better performance using 3-views images versus single-view based on greater values for accuracy, F-score, and area under the curve (AUC). The highest sensitivity was 98.7 % and specificity was 98.6 % in detection of ankle fractures using 3-views using inception V3. This model missed only one fracture on radiographs.

Conclusion: The performance of our DCNNs showed that it can be used for developing the currently used image interpretation programs or as a separate assistant solution for the clinicians to detect ankle fractures faster and more precisely.

Level Of Evidence: III.
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http://dx.doi.org/10.1016/j.fas.2022.05.005DOI Listing
May 2022

Incidence of (Osteo)Chondral Lesions of the Ankle in Isolated Syndesmotic Injuries: A Systematic Review and Meta-Analysis.

Cartilage 2022 Apr-Jun;13(2):19476035221102569

Department of Orthopaedic Surgery and Sports Medicine, Amsterdam Movement Sciences, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands.

Objective: To determine and compare the incidence rate of (osteo)chondral lesions of the ankle in patients with acute and chronic isolated syndesmotic injuries.

Design: A literature search was conducted in the PubMed (MEDLINE) and EMBASE (Ovid) databases from 2000 to September 2021. Two authors independently screened the search results, and risk of bias was assessed using the MINORS (Methodological Index for Non-Randomized Studies) criteria. Studies on acute and chronic isolated syndesmotic injuries with pre-operative or intra-operative imaging were included. The primary outcome was the incidence rate with corresponding 95% confidence intervals (CIs) of (osteo)chondral lesions of the ankle in combined and separate groups of acute and chronic syndesmotic injuries. Secondary outcomes were anatomic distribution and mean size of the (osteo)chondral lesions.

Results: Nine articles (402 syndesmotic injuries) were included in the final analysis. Overall (osteo)chondral lesion incidence was 20.7% (95% CI: 13.7%-29.9%). This rate was 22.0% (95% CI: 17.1-27.7) and 24.1% (95% CI: 15.6-35.2) for acute and chronic syndesmotic injuries, respectively. In the combined acute and chronic syndesmotic injury group, 95.4% of the lesions were located on the talar dome and 4.5% of the lesions were located on the distal tibia. (Osteo)chondral lesion size was not reported in any of the studies.

Conclusions: This meta-analysis shows that (osteo)chondral lesions of the ankle are present in 21% of the patients with isolated syndesmotic injuries. No difference in incidence rate was found between the different syndesmotic injury types and it can be concluded that the majority of lesions are located on the talar dome.

Prospero Registration Number: CRD42020176641.
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http://dx.doi.org/10.1177/19476035221102569DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9168886PMC
June 2022

Utility of Diagnostic Ultrasound in the Assessment of Patellar Instability.

Orthop J Sports Med 2022 May 23;10(5):23259671221098748. Epub 2022 May 23.

Foot & Ankle Research and Innovation Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.

Background: The use of imaging to diagnose patellofemoral instability is often limited by the inability to dynamically load the joint during assessment. Therefore, the diagnosis is typically based on physical examination using the glide test to assess and quantify lateral patellar translation. However, precise quantification with this technique remains difficult.

Purpose: To quantify patellar position using ultrasound imaging under dynamic loading conditions to distinguish between knees with and without medial patellofemoral complex (MPFC) injury.

Study Design: Controlled laboratory study.

Methods: In 10 cadaveric knees, the medial patellofemoral distance was measured to quantify patellar position from 0° to 40° of knee flexion at 10° increments. Knees were evaluated at each flexion angle under unloaded conditions and with 20 N of laterally directed force on the patella to mimic the glide test. Patellar position measurements were made on ultrasound images obtained before and after MPFC transection and compared for significant differences. To determine the ability of medial patellofemoral measurements to differentiate between MPFC-intact and MPFC-deficient states, area under the receiver operating characteristic (ROC) curve analysis and the Delong test were used. The optimal cutoff value to distinguish between the deficient and intact states was determined using the Youden statistic.

Results: A significant increase in medial patellofemoral distance was observed in the MPFC-deficient state as compared with the intact state at all flexion angles ( = .005 to < .001). When compared with the intact state, MPFC deficiency increased medial patellofemoral distance by 32.8% (6 mm) at 20° of knee flexion under 20-N load. Based on ROC analysis and the statistic, the optimal threshold for identifying MPFC injury was 19.2 mm of medial patellofemoral distance at 20° of flexion under dynamic loading conditions (area under the ROC curve = 0.93, sensitivity = 77.8%, specificity = 100%, accuracy = 88.9%).

Conclusion: Using dynamic ultrasound assessment, we found that medial patellofemoral distance significantly increases with disruption of the MPFC.

Clinical Relevance: Dynamic ultrasound measurements can be used to accurately detect the presence of complete MPFC injury.
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http://dx.doi.org/10.1177/23259671221098748DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9134436PMC
May 2022

Deep Learning Algorithms Improve the Detection of Subtle Lisfranc Malalignments on Weightbearing Radiographs.

Foot Ankle Int 2022 Aug 19;43(8):1118-1126. Epub 2022 May 19.

Foot & Ankle Research and Innovation Laboratory (FARIL), Department of Orthopaedic Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA.

Background: Detection of Lisfranc malalignment leading to the instability of the joint, particularly in subtle cases, has been a concern for foot and ankle care providers. X-ray radiographs are the mainstay in the diagnosis of these injuries; thus, improving the performance of clinicians in interpreting radiographs can noticeably affect the quality of health care in these patients. Here we assessed the performance of deep learning algorithms on weightbearing radiographs for detection of Lisfranc joint malalignment in patients with Lisfranc instability.

Methods: In a retrospective study, 640 patients with Lisfranc malalignment leading to instability were recruited plus 640 individuals with uninjured feet and healthy Lisfranc joint as the control group. All radiographs were screened by orthopaedic surgeons. Two deep learning models were trained, validated, and tested (in a ratio 80:10:10) using a single-view (anteroposterior) and 3-view (anteroposterior, lateral, oblique) radiographs. The performances of the models were reported as sensitivity, specificity, positive and negative predictive values, accuracy, score, and area under the curve (AUC).

Results: No significant differences were observed between the patients and the controls regarding age, gender, race, and body mass index. The best deep learning algorithm outperformed our human interpreters (<1% vs ~10% misdiagnosis), 94.8% sensitivity, 96.9% specificity, 98.6% accuracy, 95.8% score, and 99.4% AUC.

Conclusion: Deep learning methods have shown promising potential in acting as an assistant interpreter of radiographic images in patients with Lisfranc malalignment. Developing these algorithms can hasten and improve the accuracy of diagnosis and reduce further costs and burdens on the patients and health care system.

Level Of Evidence: Level III, case-control Machine Learning study.
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http://dx.doi.org/10.1177/10711007221093574DOI Listing
August 2022

Isolated injuries to the lateral ankle ligaments have no direct effect on syndesmotic stability.

Knee Surg Sports Traumatol Arthrosc 2022 May 6. Epub 2022 May 6.

Foot and Ankle Research and Innovation Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.

Purpose: This study aim was to detect the impact of lateral ankle ligaments injury on syndesmotic laxity when evaluated arthroscopically in a cadaveric model. The null hypothesis was that lateral ankle ligament injury does not affect the stability of syndesmosis.

Methods: Sixteen fresh-frozen above-knee amputated cadaveric specimens were divided into two groups of eight specimens that underwent arthroscopic evaluation of the distal tibiofibular joint. In both the groups, the assessment was first done with all syndesmotic and ankle ligaments intact. Thereafter, Group 1 underwent sequential transection of the three lateral ankle ligaments first to identify the effects of lateral ligament injury: (1) anterior talofibular ligament (ATFL), (2) calcaneofibular ligament (CFL), (3) posterior talofibular ligament (PTFL), then followed by the syndesmotic ligaments, (4) AITFL, (5) Interosseous ligament (IOL), and (6) PITFL. Group 2 underwent sequential transection of the (1) AITFL, (2) ATFL, (3) CFL, (4) IOL, (5) PTFL, and (6) PITFL, which represent the most commonly injured pattern in ankle sprain. In all scenarios, four loading conditions were considered under 100 N of direct force: (1) unstressed, (2) a lateral fibular hook test, (3) anterior to posterior (AP) fibular translation test, and (4) posterior to anterior (PA) fibular translation test. Distal tibiofibular coronal plane diastasis at the anterior and posterior third of syndesmosis, as well as AP and PA sagittal plane translation, were arthroscopically measured.

Results: The distal tibiofibular joint remained stable after transection of all lateral ankle ligaments (ATFL, CFL, and PTFL) as well as the AITFL. However, after additional transection of the IOL, the syndesmosis became unstable in both the coronal and sagittal plane. Syndesmosis laxity in the coronal plane was also observed after transection of the ATFL, CFL, AITFL, and IOL. Subsequent transection of the PITFL precipitated syndesmosis laxity in the sagittal plane, as well.

Conclusions: The findings from the present study suggest that lateral ankle ligament injuries itself do not directly affect the stability of syndesmosis. However, if it combines with IOL injuries, even partial injuries cause syndesmotic laxity. As a clinical relevance, accurate diagnosis is the key for surgeons to determine syndesmosis fixation whether there is only AITFL injury or combined IOL injury in concomitant acute syndesmotic and lateral ligament injury.
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http://dx.doi.org/10.1007/s00167-022-06985-6DOI Listing
May 2022

Comparison of Several Combinations of Suture Tape Reinforcement and Suture Button Constructs for Fixation of Unstable Syndesmosis.

J Am Acad Orthop Surg 2022 May 15;30(10):e769-e778. Epub 2022 Feb 15.

From the Foot & Ankle Research and Innovation Laboratory, Massachusetts General Hospital, Harvard Medical School, Weston, MA (Schermann, Ogawa, Lubberts, Taylor, Waryasz, DiGiovanni, and Guss), the Division of Orthopedic Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel (Schermann and Khoury), the Department of Orthopedic Surgery, Tokyo Medical and Dental University, Tokyo, Japan (Ogawa), the Foot & Ankle Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA (Lubberts, Waryasz, DiGiovanni, and Guss), and the Newton-Wellesley Hospital, Harvard Medical School, Newton, MA (DiGiovanni).

Introduction: The purpose of this study was to arthroscopically evaluate syndesmotic stability after fixation with several combinations of suture buttons (SBs) and suture tape reinforcement in a completely unstable cadaver model.

Methods: Fifteen cadaver above-knee specimens underwent sequential ligament transection and fixation to create six experimental models: (1) intact model, (2) after complete disruption of the syndesmotic ligaments, and after repair with either suture tape reinforcement (3), suture tape reinforcement with a single SB (4), suture tape reinforcement with two diverging SBs (5), or two diverging SBs alone (6). Instability measurements included anterior and posterior tibiofibular spaces measured arthroscopically under 100 N coronal stress, tibiofibular anteroposterior and posteroanterior translation in sagittal plane measured arthroscopically under sagittal stress of 100 N, and anterior tibiofibular space measured directly with a caliper under external rotation torque of 7.5 N·m. Instability measurements taken after each fixation method were compared with the uninjured model and with the complete unstable model using the Wilcoxon signed-rank test.

Results: Fixation using a combination of one SB and singular suture tape reinforcement augmentation provided stability similar to the intact stage (coronal anterior space 1.24 versus 1.15, P = 0.887; coronal posterior space 1.63 versus 1.64, P = 0.8421; anteroposterior translation 0.91 versus 0.46, P = 0.003; posteroanterior translation 0.51 versus 0.57, P = 0.051; external rotation anterior tibiofibular space 1.08 versus 0.55, P = 0.069). Moreover, adding a second SB led to further gains in fixation stability.

Discussion: This study suggests that although a destabilizing syndesmotic injury that includes the anterior inferior tibiofibular ligament, interosseous ligament, and posterior inferior tibiofibular ligament is not adequately stabilized by either one or two SBs, the addition of a suture tape reinforcement to even one SB restores syndesmotic stability to the preinjury level.
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http://dx.doi.org/10.5435/JAAOS-D-21-00508DOI Listing
May 2022

Radiographic Landmarks for the Femoral Attachment of the Medial Patellofemoral Complex: A Cadaveric Study.

Arthroscopy 2022 08 11;38(8):2504-2510. Epub 2022 Feb 11.

Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A. Electronic address:

Purpose: To report the radiographic landmarks for the medial patellofemoral complex (MPFC) footprint on the medial femur and describe the difference between the radiographic positions corresponding to the medial quadriceps tendon femoral ligament (MQTFL) and medial patellofemoral ligament (MPFL) fibers.

Methods: In 8 unpaired cadaveric knees, the MPFC footprint was exposed on the medial femur, and the proximal and distal boundaries of the footprint were marked. Lateral fluoroscopic images of the knee were obtained and analyzed using Image J. The proximal boundary corresponding to the MQTFL, the MPFC midpoint, and distal boundary corresponding to the MPFL were described radiographically and compared for differences in position.

Results: The proximal MQTFL footprint was 0.8 ± 0.6 mm anterior (P = .013) and 5.2 ± 1.8 mm proximal to the MPFC midpoint (P <.001), whereas the distal MPFL footprint was 0.8 ± 0.7 mm posterior (P = .012) and 5.9 ± 1.1 mm distal to the radiographic MPFC midpoint (P <.001). The radiographic point corresponding to the distal MPFL footprint was 0.8 ± 0.9 mm posterior (P = .011) and 11.1 ± 2.3 mm distal to the radiographic point of the proximal MQTFL footprint (P <.001). When using the point of intersection of the posterior cortical line and the proximal posterior condyle as a reference, 91.6% of all points correlating to the MQTFL, MPFC midpoint and MPFL, were within 10 mm in any direction from this radiographic landmark.

Conclusions: On fluoroscopic imaging, the proximal MQTFL and distal MPFL fibers had significantly different radiographic positions from the MPFC midpoint on the femur. These findings should be considered when reconstructing specific components of the MPFC.

Clinical Relevance: As fluoroscopy is often used intraoperatively to guide graft placement, our findings may serve as a reference when differentiating the locations of the MPFL vs MQTFL on the femur for anatomic reconstruction.
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http://dx.doi.org/10.1016/j.arthro.2022.01.046DOI Listing
August 2022

Use of portable ultrasonography for the diagnosis of lateral ankle instability.

J Orthop Res 2022 Jan 5. Epub 2022 Jan 5.

Foot and Ankle Research and Innovation Lab (FARIL), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.

Portable ultrasonography is increasingly used to evaluate ankle stability at the point of care. This study aims to determine the correlation of portable-ultrasonographic and fluoroscopic measurements of ankle laxity in a cadaveric ligament transection model of ankle ligament injury. We hypothesize that there is an association between portable-ultrasonographic and fluoroscopic measurements when performing stress evaluation of lateral ankle instability. Eight fresh-frozen below-knee amputated cadaveric specimens with intact proximal fibula underwent ultrasound and fluoroscopic evaluation of the ankle during anterior drawer and talar tilt testing. The assessment was first performed with all lateral ankle ligaments intact and thereafter with sequential transection of the anterior talofibular ligament, calcaneofibular ligament, and posterior talofibular ligament. The anterior drawer test was performed with both 50N and 80N of force, and talar tilt test was performed with 1.7 Nm of torque. Correlations between (1) portable-ultrasonographic and fluoroscopic measurements and (2) sequential transection of lateral ankle ligaments were evaluated using Spearman's rank correlations. The same statistical test was used to investigate the correlation between the ultrasonographic and the fluoroscopic measurements. The inter- and intra-observer agreement was assessed using the intraclass correlation coefficient through a two-way mixed-effects model with absolute agreement. Portable-ultrasonographic and fluoroscopic measurements increased as additional ligaments of the lateral ankle were transected (Spearman's rank correlation ranged from 0.74 to 0.81, 0.74 to 0.81, p-values < 0.001). Strong positive correlations between ultrasonographic and fluoroscopic measurements were found during the lateral ankle stability evaluation using anterior drawer and talar tilt testing (Spearman's rank correlation ranged from 0.81 to 0.85, 0.81 to 0.85, p-values < 0.001). Inter-rater (0.99, 95% CI: 0.98-0.99) and intra-rater reliability (0.97, 95% CI: 0.95-0.99) for the ultrasonographic measurements were substantial. In conclusion, there was a strong correlation found between ultrasonographic and fluoroscopic values measured during simulated anterior drawer and talar tilt test in a cadaveric ligament transection model. In this model, the portable-ultrasonographic measurement was found to be reliable for repeated measurements of the talar translation and the lateral clear space distance. Based on these data, ultrasonography is likely to become a valuable point of care diagnostic tool due to its ability to readily and dynamically evaluate suspected lateral ankle instability. Clinical Significance: The use of dynamic stress ultrasound to assess the anterior translation of the talus and the lateral clear space distance appears to be a reliable and repeatable technique to evaluate lateral ankle stability with a radiation-free, noninvasive, and low-cost manner.
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http://dx.doi.org/10.1002/jor.25256DOI Listing
January 2022

Utility of WBCT to Diagnose Syndesmotic Instability in Patients With Weber B Lateral Malleolar Fractures.

J Am Acad Orthop Surg 2022 Feb;30(3):e423-e433

From the Foot & Ankle Research and Innovation Laboratory, Harvard Medical School, Massachusetts General Hospital, Boston, MA (Bhimani, Ashkani-Esfahani, Lubberts, Kaiser, Waryasz, DiGiovanni, and Guss), Department of Orthopedic Surgery, Academic Medical Center, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands (Kerkhoffs), the Foot & Ankle Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA (Kaiser, Waryasz, DiGiovanni, and Guss), Newton-Wellesley Hospital, Harvard Medical School, Massachusetts General Hospital, Boston, MA (Kaiser, Waryasz, DiGiovanni, and Guss).

Background: Diagnosing syndesmotic instability accompanying Weber B ankle fractures can be challenging. This study aimed to evaluate the ability of weight-bearing computed tomography (WBCT) to diagnose syndesmotic instability using one-dimensional, two-dimensional, and three-dimensional measurements among patients with unilateral Weber B lateral malleolar fractures with symmetric medial clear space (MCS) on initial radiographs and yet demonstrated operatively confirmed syndesmotic instability.

Methods: The treatment group included 23 patients with unilateral surgically confirmed syndesmotic instability accompanying Weber B ankle fractures who underwent preoperative bilateral foot and ankle WBCT. The control group included 18 unilateral Weber B ankle fracture patients without syndesmotic instability who underwent bilateral WBCT. Measurements on WBCT images included the following: (1) syndesmotic area, (2) anterior, middle, and posterior distal tibiofibular distance, (3) fibular rotation, (4) distance from fibular tip to plafond, (5) fibular fracture displacement, and (6) MCS distance. In addition, the following volumetric measurements were calculated: (1) syndesmotic joint volume from the tibial plafond extending to 3 and 5 cm proximally, (2) MCS volume, and (3) lateral clear space volume. Area under the receiver operating characteristic curve analysis and Delong test were used, and optimal cutoff values to distinguish between stable and unstable syndesmosis were determined using Youden J statistic.

Results: Among patients with unilateral syndesmotic instability and Weber B ankle fractures, all WBCT measurements were significantly greater than uninjured side, except MCS distance, syndesmotic area, and anterior and posterior tibiofibular distances (P values <0.001 to 0.004). Moreover, syndesmosis volume spanning from the tibial plafond to 5 cm proximally had the largest area under the curve of 0.96 (sensitivity = 90%; specificity = 95%), followed by syndesmosis volume up to 3 cm proximally (area under the curve = 0.91; sensitivity = 90%; specificity = 90%). Except for MCS volume and distal fibular tip to tibial plafond distance, the control group showed no side-to-side difference in any parameter.

Conclusion: Syndesmotic joint volume measurements seem to be best suited to diagnose syndesmotic instability among patients with Weber B ankle fractures, compared with other two-dimensional and three-dimensional WBCT measurements.

Level Of Evidence: Level III, comparative diagnostic study.
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http://dx.doi.org/10.5435/JAAOS-D-21-00566DOI Listing
February 2022

The stability of total talar prosthesis-How stable to dislocation? Cadaveric study.

J Orthop Res 2021 Dec 13. Epub 2021 Dec 13.

Department of Orthopedic Surgery, Nara Medical University, Kashihara, Japan.

The aim of this study was to characterize ankle stability of total talar prosthesis (TTP) and to determine the effect of implant sizes on stability as well as the resistance to TTP dislocation. Twelve below-knee cadaveric specimens were divided into two groups. Group 1 received a size matched implant and Group 2 received downsized implant by 5%. The stability assessment under fluoroscopy was performed for each cadaver in its native state. Following TTP insertion process, each then underwent evaluation of the TTP ankle stability. The stability of pre- and post-TTP was compared. (1) Anterior drawer distance. (2) Talar tilt angle under varus and valgus stress. (3) Subtalar tilt angle under varus stress was measured. Finally, the dislocation test was performed using the aforementioned testing conditions, then the stress force was slowly increased from 0 to 350 N, during which time it was observed on fluoroscopy all the time. Compared to pre TTP ankles, varus and anterior drawer stress showed significant instability (p < 0.001-0.031). Only anterior drawer stress in smaller sized implants showed significant instability when compared to identical sized implants (p = 0.008). No dislocation was seen under varus, valgus, and subtalar stress. However, anterior dislocation was observed in all cases of smaller size implant group (p = 0.045). TTP implant was stable under valgus and subtalar stress. However, clinicians should pay attention to anterior instability. Notably, downsized implants should be considered carefully to minimize the chance of anterior dislocation.
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http://dx.doi.org/10.1002/jor.25237DOI Listing
December 2021

Portable ultrasound devices: A method to improve access to medical imaging, barriers to implementation, and the need for future advancements.

Clin Imaging 2022 01 24;81:147-149. Epub 2021 Oct 24.

Harvard Medical School, Foot & Ankle Research and Innovation Laboratory, Massachusetts General Hospital, United States of America. Electronic address:

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http://dx.doi.org/10.1016/j.clinimag.2021.10.002DOI Listing
January 2022

Does ipsilateral chronic ankle instability alter kinematics of the other joints of the lower extremities: a biomechanical study.

Int Orthop 2022 02 31;46(2):241-248. Epub 2021 Aug 31.

Foot & Ankle Research and Innovation Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA.

Purpose: We evaluated and compared kinematics of bilateral ankle, knee, and hip joints in patients with chronic unilateral ankle instability (CAI) with healthy controls.

Methods: Fifteen individuals diagnosed with CAI and a control group of 16 individuals were matched. Different peaks within the gait cycle (at different intervals) for the dorsiplantar, inversion/eversion, and abduction/adduction axis were compared between injured and uninjured sides of patients with CAI with a control group.

Results: Comparison of the uninjured ankle in CAI with the control group showed higher dorsiflexion in one peak of the stance phase (p = 0.003), higher inversion in one peak of the stance phase (p = 0.022), and the swing phase (p = 0.004). The hip joint of the uninjured side showed higher extension in one peak of the stance phase (p < 0.001), and two peaks of the swing phase (p < 0.05). Furthermore, it showed higher adduction in one peak of the foot flat to mid-stance phase (p = 0.001), higher abduction in one peak of the late swing phase (p = 0.047), and the swing phase (p = 0.032). The knee joint of the uninjured side showed higher flexion in all measured peaks of the gait cycle (p < 0.05) (except for one peak in the late swing phase) compared to the control group.

Conclusion: Chronic ankle instability results in altered biomechanics of the ipsilateral knee as well as the contralateral ankle, knee, and hip joints. The alterations caused by CAI may predispose patients to overuse and/or acute injuries of other joints of lower extremities during routine and sporting activity.
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http://dx.doi.org/10.1007/s00264-021-05139-6DOI Listing
February 2022

Medial Ankle Stability Evaluation With Dynamic Ultrasound: Establishing Natural Variations in the Healthy Cohort.

J Am Acad Orthop Surg 2021 Aug;29(16):703-713

From the Foot and Ankle Research and Innovation Lab, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Saengsin, Hagemeijer, Chang, Lubberts, Waryasz, Guss, DiGiovanni), the Department of Orthopaedic Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand (Saengsin), the Department of Orthopaedic Surgery, Faculty of Medicine, University of Tokyo, Tokyo, Japan (Chang), the Department of Orthopaedic Surgery, Academic Medical Center, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands (Hagemeijer), the Foot & Ankle Service, Department of Orthopaedic Surgery, Massachusetts General Hospital (Lubberts, Waryasz, Guss, DiGiovanni), and Massachusetts General Hospital, Newton-Wellesley Hospital (Guss, DiGiovanni), Harvard Medical School, Boston, MA.

Introduction: Destabilizing injuries to the deltoid ligament have relied on radiographic stress examination for diagnosis, with a focus on medial clear space (MCS) widening. Recently, studies have demonstrated the use of ultrasonography to assess deltoid ligament injury, but not the medial ankle stability. The purpose of this study was to assess the MCS via ultrasonography while weight-bearing and with a gravity stress test (GST) in the uninjured ankle as a means of establishing normative values for future comparison.

Methods: Twenty-six participants with no reported ankle injury in their premedical history were included. The MCS was examined using ultrasonography with the patient lying in a lateral decubitus position to replicate a GST with the ankle held in a neutral and plantarflexed position as well as while weight-bearing. The MCS was assessed in mm at the anteromedial and inferomedial aspect of the ankle joint.

Results: With weight-bearing, the average anterior MCS and inferior MCS were 3.6 and 3.3 mm, respectively. During the GST in neutral ankle position, the average anterior MCS was 4.1 mm, whereas the average inferior MCS was 4.0 mm. When measured during the GST in plantarflexed ankle position, the averages anterior MCS and inferior MCS increased to 4.4 mm. MCS values were notably higher with GST than with weight-bearing measurements (P < 0.001). MCS values were notably higher with the foot in a plantarflexed compared with a neutral position when doing GST (P < 0.001). No notable differences in MCS distance were found when comparing laterality (P > 0.05). Height had a notable effect on all MCS values (P < 0.05). Inter- and intra-rater reliabilities for ultrasonographic MCS measurements were all excellent (interclass correlation coefficient >0.75).

Discussion: Ultrasound can reliably measure the MCS of the ankle while doing dynamic stress manoeuvres. With the deltoid ligament intact, a GST increases MCS widening more than weight-bearing, and holding the ankle in plantarflexion while doing a gravity stress view, further increases this difference.

Levels Of Evidence: Diagnostic studies-investigating a diagnostic test: Level III.
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http://dx.doi.org/10.5435/JAAOS-D-20-00597DOI Listing
August 2021

Arthroscopic Patellofemoral Measurements Can Reliably Assess Patellar Instability.

Arthroscopy 2022 03 9;38(3):902-910. Epub 2021 Jul 9.

Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A.

Purpose: To arthroscopically describe patellar position based on lateralization, tilt, and engagement, and compare measurements in normal, medial patellofemoral complex-(MPFC) deficient, and MPFC-reconstructed knees.

Methods: In 10 cadaveric knees, arthroscopic patellar position was assessed by performing digital measurements on arthroscopic images obtained through a standard anterolateral portal. Lateralization was measured as millimeters overhang of the patella past the lateral edge of the lateral femoral condyle, viewing from the lateral gutter. Patellar tilt was calculated as the difference in medial and lateral distances from the patella to the trochlea, viewing from the sunrise view. Patellotrochlear distance was measured as the anteroposterior distance between the central trochlear groove and patella on the sunrise view. Measurements were obtained at 10° intervals of knee flexion from 0° to 90°, in intact knees (group 1), after arthroscopically transecting the MPFC fibers (group 2), and after MPFC reconstruction (group 3). Optimal cutoff values were identified to distinguish between intact versus MPFC-deficient states.

Results: When compared to group 1, group 2 demonstrated increased patellar lateralization by 22.5% at 0°-40° knee flexion (P = .006), which corrected to baseline in group 3 (P = .006). Patellar tilt measurements demonstrated no differences between groups. Patellotrochlear distance increased by 21.0% after MPFC transection (P = .031) at 0°-40° knee flexion, with correction to baseline after MPFC reconstruction (P = .031). More than 7 mm of lateral overhang at 20°-30° flexion and >6 mm of patellotrochlear distance at 10°-20° flexion were found to indicate MPFC deficiency.

Conclusions: Utilizing standardized arthroscopic views, we identified significant increases in patellar lateralization and patellotrochlear distance in early knee flexion angles after MPFC transection, and these changes normalized after MPFC reconstruction.

Clinical Relevance: Arthroscopic assessments of patellar position may be useful in evaluating patellofemoral stability during patellar stabilization surgery.
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http://dx.doi.org/10.1016/j.arthro.2021.06.022DOI Listing
March 2022

Do Coronal or Sagittal Plane Measurements Have the Highest Accuracy to Arthroscopically Diagnose Syndesmotic Instability?

Foot Ankle Int 2021 Jun 23;42(6):805-809. Epub 2021 Apr 23.

Foot & Ankle Research and Innovation Laboratory, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA.

Background: To compare the accuracy of arthroscopic sagittal versus coronal plane distal tibiofibular motion toward diagnosing syndesmotic instability.

Methods: Arthroscopic assessment of the syndesmosis was performed on 21 above-knee cadaveric specimens, first with all ligaments intact and subsequently with sequential transection of the anterior inferior tibiofibular ligament, the interosseous ligament, the posterior inferior tibiofibular ligament, and the deltoid ligament. A lateral hook test, an anterior-to-posterior (AP) translation test, and a posterior-to-anterior (PA) translation test were performed under 100 N of applied force. Anterior and posterior third coronal plane diastasis and AP and PA sagittal plane fibular translations were measured relative to the static tibia.

Results: Receiver operating characteristic (ROC) curve analysis revealed that the area under the curve (AUC) was higher for the combined AP and PA sagittal measurements (AUC, 0.91; accuracy, 83.5%; sensitivity, 78%; specificity, 89%) than the coronal plane measurements (anterior third: AUC, 0.65; accuracy, 60.5%; sensitivity, 63%; specificity, 59%; posterior third: AUC, 0.73; accuracy, 68.5%; sensitivity, 80%; specificity, 57%) ( < .001), underscoring the higher accuracy of sagittal plane measurements.

Conclusion: Arthroscopic measurement of sagittal plane fibular translation is more accurate than coronal plane diastasis for evaluating syndesmotic instability.

Clinical Relevance: Clinicians should focus on distal tibiofibular motion in the sagittal plane when arthroscopically evaluating suspected syndesmotic instability.

Level Of Evidence: Biomechanical cadaveric study.
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http://dx.doi.org/10.1177/10711007211004151DOI Listing
June 2021

Arthroscopic characterization of syndesmotic instability in the coronal plane: Exactly what measurement matters?

Injury 2021 Jul 9;52(7):1964-1970. Epub 2021 Apr 9.

Foot and Ankle Research and Innovation Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Foot and Ankle Service, Department of Orthopaedic Surgery, Massachusetts General Hospital and Newton-Wellesley Hospital, Harvard Medical School, Boston, MA, USA.

Background: Although ankle arthroscopy is increasingly used to diagnose syndesmotic instability, precisely where in the incisura one should measure potential changes in tibiofibular space or how much tibiofibular space is indicative of instability, however, remains unclear. The purpose of this study was to determine where within the incisura one should assess coronal plane syndesmotic instability and what degree of tibiofibular space correlates with instability in purely ligamentous syndesmotic injuries under condition of lateral hook stress test (LHT) assessment.

Methods: Ankle arthroscopy was performed on 22 cadaveric specimens, first with intact ankle ligaments and then after sequential sectioning of the syndesmotic and deltoid ligaments. At each step, a 100N lateral hook test was applied through a lateral incision 5 cm proximal to the ankle joint and the coronal plane tibiofibular space in the stressed and unstressed states were measured at both anterior and posterior third of the distal tibiofibular joint, using calibrated probes ranging from 0.1 to 6.0 mm, in 0.1 mm of increments. The anterior and posterior points of measurements were defined as the junction between the anterior and middle third, and junction between posterior and middle third of the incisura, respectively.

Results: Anterior third tibiofibular space measurements did not correlate significantly with the degree of syndesmotic instability after transection of the ligaments, neither before nor after applying LHT at all the three groups of different sequences of ligament transection (P range 0.085-0.237). In contrast, posterior third tibiofibular space measurements correlated significantly with the degree of syndesmotic instability after transection of the ligaments, both with and without applying stress in all the groups of different ligament transection (P range <0.001-0.015). Stressed tibiofibular space measurements of the posterior third showed higher sensitivity and specificity when compared to the stressed anterior third measurements. Using 2.7 mm as a cut off for posterior third stressed measurements has both sensitivity and specificity about 70 %.

Conclusion: Syndesmotic ligament injury results in coronal plane instability of the distal tibiofibular articulation that is readily identified arthroscopically with LHT when measured in the posterior third of the incisura.

Clinical Relevance: When applying LHT, tibiofibular space measurement for coronal plane instability along the anterior third of the incisura is less sensitive for identifying syndesmotic instability and may miss this diagnosis especially when subtle.
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http://dx.doi.org/10.1016/j.injury.2021.04.030DOI Listing
July 2021

Volume measurements on weightbearing computed tomography can detect subtle syndesmotic instability.

J Orthop Res 2022 02 19;40(2):460-467. Epub 2021 Apr 19.

Department of Orthopaedic Surgery, Foot and Ankle Research and Innovation Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.

While weightbearing computed tomography (WBCT) allows three-dimensional (3D) visualization of the distal syndesmosis, image interpretation has largely relied on one-dimensional (1D) distance and, more recently, two-dimensional (2D) area measurements. This study aimed to (1) determine the sensitivity and specificity of 2D area and 3D volume WBCT measurements towards detecting subtle syndesmotic instability, (2) evaluate whether the patterns of changes in the 3D shape of the syndesmosis can be attributed to the type of ligament injury. A total of 24 patients with unilateral subtle syndesmotic instability and 24 individuals with uninjured ankles (controls) with bilateral ankle WBCT were assessed retrospectively. First, 2D areas at 0, 1, 3, 5, and 10 cm, and 3D volumes at 1, 3, 5, and 10 cm above the tibial plafond were measured bilaterally. Secondly, the 3D model of the distal tibiofibular space was created based on WBCT in a subset of 8 out of 24 patients in whom the type of ligament injury was recognized via magnetic resonance imaging. The 3D model of the injured side was superimposed on the uninjured contralateral side to visualize the pattern of changes in different planes. Volume measurement up to 5 cm above the tibial plafond showed the lowest p-value (<0.001 vs. other methods), higher sensitivity (95.8%, 95% confidence interval [CI]: 87.8-100), and specificity (83.3%, 95% CI: 68.4-98.2) for detection of syndesmotic instability. No specific pattern of changes in the 3D shape could be attributed to a type of ligament rupture. We suggest 3D volume measurements, best measured up to 5 cm proximal to the plafond, as a promising means of diagnosing syndesmotic instability, particularly for subtle cases that are hard to detect. Clinical significance: The ability to compare the ankle joints bilaterally in a 3D manner under physiologic weight provided by weightbearing CT has led to a more accurate diagnostic method. Using volumetric measurement up to 5 cm above the tibial plafond showed higher sensitivity and specificity for recognizing an unstable syndesmosis, especially in subtle cases. However, our preliminary investigations showed that the pattern of 3D alterations in the distal tibiofibular joint space based on WBCT images does not indicate the type of syndesmotic ligamentous injury. Our results can also help image viewing programs to improve their measurement tools to facilitate 3D measurement for the syndesmosis as well as other conditions that may benefit from 3D evaluation of the clinical images.
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http://dx.doi.org/10.1002/jor.25049DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8497639PMC
February 2022

Biomechanics Following Anatomic Lateral Ligament Repair of Chronic Ankle Instability: A Systematic Review.

J Foot Ankle Surg 2021 Jul-Aug;60(4):762-769. Epub 2020 Oct 7.

Professor of Orthopaedic Surgery, Foot and Ankle Research and Innovation Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Chief of Division of Foot & Ankle Surgery, Department of Orthopaedic Surgery, Foot & Ankle Service, Massachusetts General Hospital, Boston, MA; President-Elect, American Orthopaedic Foot and Ankle Society, Newton-Wellesley Hospital, Harvard Medical School, Massachusetts General Hospital, Boston, MA.

One of the most common orthopedic injuries in the general population, particularly among athletes, is ankle sprain. We investigated the literature to evaluate the known pre- and postoperative biomechanical changes of the ankle after anatomic lateral ligament repair in patients suffering from chronic ankle instability. In this systematic review, studies published till January 2020 were identified by using synonyms for "kinetic outcomes," "kinematic outcomes," "Broström procedure," and "lateral ligament repair." Included studies reported on pre- and postoperative kinematic and/or kinetic data. Twelve articles, including 496 patients treated with anatomic lateral ligament repair, were selected for critical appraisal. Following surgery, both preoperative talar tilt and anterior talar translation were reduced similarly to the values found in the uninjured contralateral side. However, 16 of 152 (10.5%) patients showed a decrease in ankle range of motion after the surgery. Despite the use of these various techniques, there were no identifiable differences in biomechanical postoperative outcomes. Anatomic lateral ligament repair for chronic ankle instability can restore ankle biomechanics similar to that of healthy uninjured individuals. There is currently no biomechanical evidence to support or refute a biomechanical advantage of any of the currently used surgical ligament repair techniques mentioned among included studies.
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http://dx.doi.org/10.1053/j.jfas.2020.09.017DOI Listing
July 2021

Using area and volume measurement via weightbearing CT to detect Lisfranc instability.

J Orthop Res 2021 Nov 6;39(11):2497-2505. Epub 2021 Jan 6.

Foot & Ankle Research and Innovation Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA.

Weightbearing CT (WBCT) allows evaluation of the Lisfranc joint under physiologic load. We compared the diagnostic sensitivities of one-dimensional (1D) distance, two-dimensional (2D) area, and three-dimensional (3D) volumetric measurement of the injured Lisfranc joint complex (tarsometatarsal, intertarsal, and intermetatarsal) on WBCT among patients with surgically-confirmed Lisfranc instability. The experimental group comprised of 14 patients having unilateral Lisfranc instability requiring operative fixation who underwent preoperative bilateral foot and ankle WBCT. The control group included 36 patients without foot injury who underwent similar imaging. Measurements performed on WBCT images included: (1) Lisfranc joint (medial cuneiform-base of second metatarsal) area, (2) C1-C2 intercuneiform area, (3) C1-M2 distance, (4) C1-C2 distance, (5) M1-M2 distance, (6) first tarsometatarsal (TMT1) angular alignment, (7) second tarsometatarsal (TMT2) angular alignment, (8) TMT1 dorsal step off distance, and (9) TMT2 dorsal step-off distance. In addition, the volume of the Lisfranc joint in the coronal and axial plane were calculated. Among patients with unilateral Lisfranc instability, all WBCT measurements were increased on the injured side as compared to the contralateral uninjured side (p values:  <.001-.008). Volumetric measurements in the coronal and axial plane had a higher sensitivity (92.3%; 91.6%, respectively) and specificity (97.7%; 96.5%, respectively) than 2D and 1D Lisfranc joint measurements, suggesting them to be the most accurate in diagnosing Lisfranc instability. The control group showed no difference in any of the measurements between the two sides. WBCT scan can effectively differentiate between stable and unstable Lisfranc injuries. Lisfranc joint volume measurements demonstrate high sensitivity and specificity, suggesting that this new assessment has high clinical implications for diagnosing subtle Lisfranc instability.
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http://dx.doi.org/10.1002/jor.24970DOI Listing
November 2021

Combination Lower Extremity Nerve Blocks and Their Effect on Postoperative Pain and Opioid Consumption: A Systematic Review.

J Foot Ankle Surg 2021 Jan-Feb;60(1):121-131. Epub 2020 Sep 3.

Orthopaedic Surgeon, Department of Orthopaedic Surgery, Foot and Ankle Service, Harvard Medical School, Massachusetts General Hospital and Newton-Wellesley Hospital, Boston, MA.

The purpose of this study was to perform a systematic review of the literature examining postoperative outcomes following single site and combined peripheral nerve blocks (PNBs), including (1) sciatic and femoral nerve, (2) popliteal and saphenous nerve, and (3) popliteal and ankle nerve, during elective foot and ankle surgery. We hypothesized that combination blocks would decrease postoperative narcotic consumption and afford more effective postoperative pain control as compared to general anesthesia, spinal anesthesia, or single site PNBs. A review of the literature was performed according to the PRISMA guidelines. Medline, EMBASE, and the Cochrane Library were searched from January 2009 to October 2019. We identified studies by using synonyms for "foot," "ankle" "pain management," "opioid," and "nerve block." Included articles explicitly focused on elective foot and ankle procedures performed under general anesthesia, spinal anesthesia, PNB, or with some combination of these techniques. PNB techniques included femoral, adductor canal, sciatic, popliteal, saphenous, and ankle blocks, as well as blocks that combined multiple anatomic sites. Outcomes measured included postoperative narcotic consumption as well as patient-reported efficacy of pain control. Twenty-eight studies encompassing 6703 patients were included. Of the included studies, 57% were randomized controlled trials, 18% were prospective comparison studies, and 25% were retrospective comparison studies. Postoperative opioid consumption and postoperative pain levels were reduced over the first 24 to 48 hours with the use of combined PNBs when compared with single site PNBs, both when used as primary anesthesia or when used in concert with general anesthesia either alone or combined with systemic/local anesthesia in the first 24 to 48 hours following surgery. Studies demonstrated higher reported patient satisfaction of postoperative pain control in patients who received combined PNB. Nine of 14 (64%) studies reported no neurologic related complications with an overall reported rate among all studies ranging from 0% to 41%. Our study identified substantial improvement in postoperative pain levels, postoperative opioid consumption, and patient satisfaction in patients receiving PNB when compared with patients who did not receive PNB. Published data also demonstrated that combination PNB are more effective than single-site PNB for all data points. Notably, the addition of a femoral nerve block to a popliteal nerve block during use of a thigh tourniquet, as well as addition of either saphenous or ankle blockade to popliteal nerve block during use of calf tourniquet, may increase overall block effectiveness. Serious complications including neurologic damage following PNB administration are rare but do exist.
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http://dx.doi.org/10.1053/j.jfas.2020.08.026DOI Listing
June 2021

The protective effects of grape seed oil on induced osteoarthritis of the knee in male rat models.

J Orthop Surg Res 2020 Sep 10;15(1):400. Epub 2020 Sep 10.

Center of Nanotechnology in Drug Delivery, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran.

Background: Osteoarthritis (OA), though being treated via various methods and medicines, is still a major healthcare concern mostly due to the increase in diagnosis of these age-related diseases. The present study aimed at investigating the effects of oral and intra articular injection of grape seed oil on OA in male rat models.

Methods And Materials: Seventy male rats were selected and their anterior cruciate ligament was cut to induce OA. They were divided into 7 groups (n = 10): C1, no treatment; C2, receiving 300 mg/day of Piascledine per os (PO); C3, 1 mg sodium hyaluronate intra-articularly in days 1, 7, 14; C4, 1 mg methyl-prednisolone acetate intra-articularly; E1, avocado and grape seed oil combination (2:1, 300 mg/day) PO; E2, 500 mg/day of grape seed oil PO; E3, 200 mg/day grape seed oil intra-articularly. After 10 weeks, the rats were anesthetized and evaluated radiologically and histopathologically. P value ≤ 0.05 was considered as statistically significant.

Results: All the groups made significant differences with C1 regarding all inspected radiological criteria (P ≤ 0.05). E1 and E3 showed significantly better effects on medial femoral condyle, medial tibial condyle, joint space width, total osteophyte, and OA scores (P ≤ 0.04). Joint surface, matrix, cell distribution, cell population viability, calcification, and subchondral bone in treatment groups had significantly better scores versus C1 (P ≤ 0.04). E1 and E3 had significantly superior results regarding joint surface, cell viability, and calcification (P ≤ 0.04).

Conclusions: Grape seed oil has protective effects, both in injectable form and PO in combination with avocado, on OA in rats. Further clinical trials are necessary.
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http://dx.doi.org/10.1186/s13018-020-01932-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7488061PMC
September 2020

Utility of Volumetric Measurement via Weight-Bearing Computed Tomography Scan to Diagnose Syndesmotic Instability.

Foot Ankle Int 2020 07 17;41(7):859-865. Epub 2020 May 17.

Foot & Ankle Research and Innovation Laboratory, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA.

Background: Weight-bearing computed tomography (WBCT) allows evaluation of the distal syndesmosis under physiologic load. We hypothesized that WBCT volumetric measurement of the distal syndesmosis would be increased on the injured as compared to the contralateral uninjured side and that these 3-dimensional (3D) calculations would be a more sensitive determinant than 2-dimensional (2D) methodology among patients with syndesmotic instability.

Methods: Twelve patients with unilateral syndesmotic instability requiring operative fixation who underwent preoperative bilateral foot and ankle WBCT were included in the study group. The control group consisted of 24 patients without ankle injury who underwent similar imaging. On WBCT scan, 2D measurements of the syndesmosis joint were first measured 1 cm above the joint line in the axial plane via syndesmotic area and distances between the anterior, middle, and posterior quadrants. Thereafter, comparative 3D volumetric measurements of the syndesmotic joint were also calculated: (1) from the tibial plafond extending until 3 cm proximally, (2) 5 cm proximally, and (3) 10 cm proximally.

Results: In patients with unilateral syndesmotic instability, all 3 weight-bearing volumetric measurements were significantly larger on the injured side as compared to the contralateral, uninjured side ( < .001). In the control group, there was no difference between syndesmotic volumes at any level. Of these 3 anatomic reference points, the 3D measurement spanning from the tibial plafond to a level 5 cm proximally had the highest relative volumetric ratio between the injured and uninjured side, suggesting it is the most sensitive in distinguishing between stable and unstable syndesmotic injury ( < .001). Notably, this 3D volumetric measurement was also more sensitive than 2D measurements ( = .001).

Conclusion: 3D volumetric measurement of the syndesmosis joint appears to be the most effective way to diagnose syndesmotic instability, compared with more traditional 2D syndesmosis measurement.

Level Of Evidence: Level III, retrospective comparative study.
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http://dx.doi.org/10.1177/1071100720917682DOI Listing
July 2020

Factors associated with adverse events after distal tibiofibular syndesmosis fixation.

Injury 2020 Feb 9;51(2):542-547. Epub 2019 Dec 9.

Division of Foot & Ankle Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital/Newton-Wellesley Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, United States of America. Electronic address:

Purpose And Hypothesis: Factors associated with adverse outcomes following surgery for syndesmotic instability with associated closed fibula fracture are incompletely understood. The purpose of this study was to determine the pathoetiology and incidence of adverse events after stabilization of syndesmotic instability. In addition, we aimed to identify any patient or surgeon related factors that might be associated with unanticipated outcomes.

Methods: Between January 2000 and May 2015, a total of 849 adult patients who were surgically treated with either screw or suture button fixation for syndesmotic instability with associated fibula fracture without open wound were identified and retrospectively evaluated. Multivariable logistic regression analyses were used to determine factors associated with any postoperative complication or unplanned reoperation.

Results: Within one year after surgery, 10.7% (91 patients) suffered an infectious complication and 22.0% (187 patients) underwent unplanned reoperation. Factors associated with infectious complications were increased duration of hospital admission (OR: 1.08, p = .014), use of an external fixator device before ORIF (OR: 5.19 p < .001), peripheral vascular disease (OR: 4.33, p = .008), and osteoporosis (OR: 2.71, p = .022). For unplanned hardware removal specifically, patients' BMI below 30 was an associated risk factor. (OR: 1.50, p = .010).

Conclusion: Certain patient groups have an increased risk of adverse events following the use of current surgical fixation methods for stabilizing the syndesmosis. Patients undergoing surgery for syndesmotic instability with associated fibula fracture without open wound should be counseled that up to 1 in 10 suffer an infectious complication and that 1 in 5 require unplanned hardware removal.
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http://dx.doi.org/10.1016/j.injury.2019.12.011DOI Listing
February 2020

Arthroscopic Assessment of Syndesmotic Instability in the Sagittal Plane in a Cadaveric Model.

Foot Ankle Int 2020 02 8;41(2):237-243. Epub 2019 Oct 8.

Massachusetts General Hospital, Newton-Wellesley Hospital, Harvard Medical School, Boston, MA, USA.

Background: Syndesmotic instability is multidirectional, occurring in the coronal, sagittal, and rotational planes. Despite the multitude of studies examining such instability in the coronal plane, other studies have highlighted that syndesmotic instability may instead be more evident in the sagittal plane. The aim of this study was to arthroscopically assess the degree of syndesmotic ligamentous injury necessary to precipitate fibular translation in the sagittal plane.

Methods: Twenty-one above-knee cadaveric specimens underwent arthroscopic evaluation of the syndesmosis, first with all syndesmotic and ankle ligaments intact and subsequently with sequential sectioning of the anterior inferior tibiofibular ligament (AITFL), the interosseous ligament (IOL), the posterior inferior tibiofibular ligament (PITFL), and deltoid ligament (DL). In all scenarios, an anterior to posterior (AP) and a posterior to anterior (PA) fibular translation test were performed under a 100-N applied force. AP and PA sagittal plane translation of the distal fibula relative to the fixed tibial incisura was arthroscopically measured.

Results: Compared with the intact ligamentous state, there was no difference in sagittal fibular translation when only 1 or 2 ligaments were transected. After transection of all the syndesmotic ligaments (AITFL, IOL, and PITFL) or after partial transection of the syndesmotic ligaments (AITFL, IOL) alongside the DL, fibular translation in the sagittal plane significantly increased as compared with the intact state ( values ranging from .041 to <.001). The optimal cutoff point to distinguish stable from unstable injuries was equal to 2 mm of fibular translation for the total sum of AP and PA translation (sensitivity 77.5%; specificity 88.9%).

Conclusion: Syndesmotic instability appears in the sagittal plane after injury to all 3 syndesmotic ligaments or after partial syndesmotic injury with concomitant deltoid ligament injury in this cadaveric model. The optimal cutoff point to arthroscopically distinguish stable from unstable injuries was 2 mm of total fibular translation.

Clinical Relevance: These data can help surgeons arthroscopically distinguish between stable syndesmotic injuries and unstable ones that require syndesmotic stabilization.
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http://dx.doi.org/10.1177/1071100719879673DOI Listing
February 2020

Venous Thromboembolism and Bleeding Adverse Events in Lower Leg, Ankle, and Foot Orthopaedic Surgery with and without Anticoagulants.

J Bone Joint Surg Am 2019 Mar;101(6):539-546

Department of Orthopaedic Surgery, Massachusetts General Hospital, Newton-Wellesley Hospital, Harvard Medical School, Boston, Massachusetts.

Background: Currently, there is insufficient knowledge about the benefits of anticoagulant use for primary prevention of venous thromboembolism (VTE) and its inherent risk of bleeding adverse events in patients undergoing surgery distal to the knee.

Methods: The study included patients who had undergone an orthopaedic procedure distal to the tibial articular surface when they were 18 years of age or older. Using retrospective information from a tertiary care referral center, we compared patient demographics, clinical findings, diagnostic reports, procedures performed, and the rate of symptomatic VTE and bleeding adverse events between patients who had and those who had not received anticoagulant prophylaxis. Propensity score matching was used to minimize selection bias due to prophylactic treatment allocation.

Results: A total of 5,286 patients who had received anticoagulant prophylaxis for below-the-knee surgery were successfully matched with 5,286 patients who had not received anticoagulant prophylaxis for such surgery. After propensity score matching, the standardized difference between the groups was <0.1 for all baseline characteristics, indicating a negligible difference between the groups. Patients who received anticoagulant prophylaxis had a significantly lower risk of developing a VTE compared with patients who did not (39 patients [0.7%] versus 99 patients [1.9%]), with an odds ratio (OR) of 0.38 (95% confidence interval [CI], 0.25 to 0.56; p < 0.001). In contradistinction, patients who received anticoagulant prophylaxis had a significantly higher risk of developing a bleeding adverse event than those who did not (115 [2.2%] versus 55 [1.0%]; OR, 2.18 [95% CI, 1.55 to 3.09]; p < 0.001).

Conclusions: Anticoagulant prophylaxis reduced the risk of VTE after surgery distal to the tibial articular surface by 3-fold but resulted in a concomitant 2-fold increase in the risk of a bleeding adverse event. Large-scale, prospective studies are necessary to better understand the true incidence of such events, associated patient-specific risk factors, efficacy of various thromboprophylactic regimens, and patient-reported implications of such events.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.18.00346DOI Listing
March 2019

Adverse Events and Their Risk Factors Following Intra-articular Corticosteroid Injections of the Ankle or Subtalar Joint.

Foot Ankle Int 2019 Jun 13;40(6):622-628. Epub 2019 Mar 13.

2 Harvard Medical School, Department of Orthopaedic Surgery, Massachusetts General Hospital/Newton-Wellesley Hospital, Boston, MA, USA.

Background: Little data exists regarding the incidence of adverse events and their associated risk factors following intra-articular corticosteroid injection of the ankle and subtalar joint. The aim of this study was to determine the complication rate associated with such injections and to identify any predictive risk factors.

Methods: Adult patients who had received an intra-articular ankle or subtalar joint injection between January 2000 and April 2016 at one of 3 regional hospitals (2 level 1 trauma centers and 1 community hospital) were included. Patients with prior intra-articular injection of corticosteroid into the ankle or subtalar joint were excluded. Explanatory variables were sex, age, race, body mass index, diabetes status, tobacco use, presence of fluoroscopic guidance, location of intra-articular injection, and administering physician's years of experience.

Results: Of the 1708 patients included in the final cohort, 99 patients (5.8%) had a total of 104 adverse events within 90 days postinjection. The most prevalent types of adverse events were postinjection flare in 78 patients (4.6% of total cohort, 75% of adverse events) followed by skin reaction in 10 patients (0.6% of total cohort, 9% of adverse events). No infections were noted. Multivariable logistic regression analysis found that intra-articular injection in the subtalar ( P = .004) was independently associated with development of an adverse event. Fluoroscopic guidance was not found to be protective of an adverse event compared to nonguided injections ( P = .476).

Conclusion: The adverse event rate following intra-articular ankle or subtalar joint corticosteroid injection was 5.8%, with postinjection flare being the most common complication. Infections following injection were not reported. Injection into the subtalar joint was independently associated with the development of an adverse event after intra-articular corticosteroid injection, and this was not mitigated by the use of fluoroscopic guidance.

Level Of Evidence: Level III, retrospective comparative study.
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http://dx.doi.org/10.1177/1071100719835759DOI Listing
June 2019

Postoperative Complications Following Repair of Acute Achilles Tendon Rupture.

Foot Ankle Int 2019 Jun 27;40(6):679-686. Epub 2019 Feb 27.

2 Orthopaedic Foot and Ankle Service, Massachusetts General Hospital - Harvard Medical School, Newton-Wellesley Hospital, MA, USA.

Background: Controversy remains regarding which patients with acute Achilles tendon rupture would best be treated nonoperatively and which might benefit from operative repair. The primary aim of this study was to characterize the overall incidence of-and specific risk factors associated with-postoperative complications that follow operative repair. We also evaluated the specific differences between complications after the use of an open or minimally invasive surgical (MIS) approach.

Methods: Retrospective chart review identified 615 adult patients who underwent operative repair for an acute Achilles tendon rupture between January 1, 2001, and May 1, 2016, at 3 level I trauma centers. Minimum follow-up was 3 months. Patient demographics, comorbidities, injury mechanism, procedural details, and surgeon subspecialty were collected. Assessed complications included wound healing issues, rerupture, hematoma, nerve injury, deep vein thrombosis, and pulmonary embolism.

Results: Seventy-two patients (11.7%) developed a postoperative complication. Risk factors included advancing patient age (odds ratio [OR], 1.04, P = .007), active tobacco use (OR, 3.20, P = .007), and specific subspecialty training (OR, 2.04, P = .046). No difference in overall complication rate was found between the open and MIS approaches (11.6% vs 13.2%, P = .658). A subgroup analysis among orthopedic subspecialties demonstrated that patients treated by trauma surgeons had increased rates of wound complication ( P = .043) and rerupture ( P = .025) compared with those treated by other subspecialties. Patients treated by trauma surgeons were also more likely to be younger or have a body mass index (BMI) > 30, although neither factor was found to be independently predictive for postoperative complications.

Conclusion: Approximately 1 in 9 patients undergoing operative repair of an acute Achilles tendon rupture developed a postoperative complication. Advancing age and active tobacco use were independent risk factors for developing such complications. Differences in subspecialty training also appear to impact complication rates, but the potential reason for this discrepancy remains unclear. As controversy remains regarding which patients who sustain acute Achilles tendon rupture should be treated nonoperatively and which would benefit most from surgical repair, a better understanding of postoperative complication rates and associated risk factors may enhance the decision-making processes in treating these injuries. It is not clear whether MIS techniques are superior to traditional open repair in terms of postoperative complications.

Level Of Evidence: Level III, retrospective comparative series.
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http://dx.doi.org/10.1177/1071100719831371DOI Listing
June 2019

The arthroscopic syndesmotic assessment tool can differentiate between stable and unstable ankle syndesmoses.

Knee Surg Sports Traumatol Arthrosc 2020 Jan 26;28(1):193-201. Epub 2018 Oct 26.

Division of Foot & Ankle Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital, Newton-Wellesley Hospital, Harvard Medical School, Boston, USA.

Purpose: Patients with stable isolated injuries of the ankle syndesmosis can be treated conservatively, while unstable injuries require surgical stabilisation. Although evaluating syndesmotic injuries using ankle arthroscopy is becoming more popular, differentiating between stable and unstable syndesmoses remains a topic of on-going debate in the current literature. The purpose of this study was to quantify the degree of displacement of the ankle syndesmosis using arthroscopic measurements. The hypothesis was that ankle arthroscopy by measuring multiplanar fibular motion can determine syndesmotic instability.

Methods: Arthroscopic assessment of the ankle syndesmosis was performed on 22 fresh above knee cadaveric specimens, first with all syndesmotic and ankle ligaments intact and subsequently with sequential sectioning of the anterior inferior tibiofibular ligament, the interosseous ligament, the posterior inferior tibiofibular ligament, and deltoid ligaments. In all scenarios, four loading conditions were considered under 100N of direct force: (1) unstressed, (2) a lateral hook test, (3) anterior to posterior (AP) translation test, and (4) posterior to anterior (PA) translation test. Anterior and posterior coronal plane tibiofibular translation, as well as AP and PA sagittal plane translation, were arthroscopically measured.

Results: As additional ligaments of the syndesmosis were transected, all arthroscopic multiplanar translation measurements increased (p values ranging from p < 0.001 to p = 0.007). The following equation of multiplanar fibular motion relative to the tibia measured in millimeters: 0.76*AP sagittal translation + 0.82*PA sagittal translation + 1.17*anterior third coronal plane translation-0.20*posterior third coronal plane translation, referred to as the Arthroscopic Syndesmotic Assessment tool, was generated from our data. According to our results, an Arthroscopic Syndesmotic Assessment value equal or greater than 3.1 mm indicated an unstable syndesmosis.

Conclusions: This tool provides a more reliable opportunity in determining the presence of syndesmotic instability and can help providers decide whether syndesmosis injuries should be treated conservatively or operatively stabilized. The long-term usefulness of the tool will rest on whether an unstable syndesmosis correlates with acute or chronic clinical symptoms.
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http://dx.doi.org/10.1007/s00167-018-5229-3DOI Listing
January 2020
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