Publications by authors named "Daniel Guss"

64 Publications

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

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

Short-Term Risk Factors for Subtalar Arthrodesis After Primary Tibiotalar Arthrodesis.

J Foot Ankle Surg 2022 Apr 10. Epub 2022 Apr 10.

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

While adjacent joint arthritis is a recognized long-term downside of primary tibiotalar arthrodesis (TTA), few studies have identified risk factors for early subtalar arthrodesis (STA) after TTA. This study aims to identify the risk factors for STA within the first few years following TTA. All patients older than 18 years undergoing TTA between 2008 and 2016 were identified retrospectively. Demographic data and comorbidities were collected alongside prior operative procedures, postoperative complications, and subsequent STA. Pre-and postoperative Kellgren-Lawrence osteoarthritis grade of the subtalar joint and postoperative radiographic alignment were obtained. A total of 240 patients who underwent primary TTA were included in this study with median follow up of 13.8 months. Twenty patients (8.3%) underwent STA after TTA due to symptomatic nonunion of TTA in 13 (65%), progression of symptomatic subtalar osteoarthritis (OA) in 4 (20%), and symptomatic nonunion of primary TTA combined progressively symptomatic subtalar OA in 2 (10%). Preoperative radiographic subtalar OA severity and postoperative radiographic alignment were not correlated with subsequent STA. Diabetes mellitus, Charcot arthropathy, neuropathy, alcohol use, substance use disorder, and psychiatric disease were significantly associated with having a subsequent STA. The most common postoperative contributing factor for subsequent STA following primary TTA was the salvage of symptomatic ankle nonunion rather than subtalar joint disease. Patients considering an ankle fusion should be counseled of the risk of subsequent STA, especially if they have risk factors that include diabetes, Charcot arthropathy, neuropathy, alcohol use, substance use disorder, or psychiatric disease.
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http://dx.doi.org/10.1053/j.jfas.2022.04.001DOI Listing
April 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

Novel values in the radiographic diagnosis of ligamentous Lisfranc injuries.

Injury 2022 Jun 22;53(6):2326-2332. Epub 2022 Feb 22.

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

Background: Ligamentous Lisfranc instability is commonly missed on unilateral radiographs. However, measurement protocols for bilateral weightbearing radiographs have not been standardized. The primary aim of this study was to investigate the optimal cut-off values for diagnosing Lisfranc instability by evaluating the side-to-side differences of preoperative bilateral weightbearing radiographs among patients with surgically-confirmed ligamentous Lisfranc instability. A secondary aim was to investigate whether the midfoot measurements for detecting Lisfranc injury could also be used in patients with a pre-existing bilateral Hallux Valgus (HV) deformity by evaluating whether the Lisfranc measurements could be affected by a foot deformity as HV.

Patients And Methods: Patients who underwent surgical repair of ligamentous Lisfranc instability, as well as a separate cohort with bilateral hallux valgus deformity, were included in this multicenter retrospective cohort study. A standardized radiographic measurement protocol was used to assess the midfoot and a receiver operator correlation (ROC) analysis was used to identify the optimal cut-off value for measurements. Interclass Correlation (ICC) scores were calculated to assess the interrater reliability of the Lisfranc area measurement.

Results: Forty-seven patients were included in the Lisfranc group with a mean age of 33 (± 15) years and 25 patients were included in the HV group with a mean age of 51 (± 15) years. For the Lisfranc group, measurements that demonstrated a significant side-to-side difference included; increased C1M2 diastasis of 2.4 mm (± 1.4, P<0.001), increased C1M2 surface area of 24 mm (± 15, P<0.001), C2M2 malignment by 1.7 mm (± 1.2, P<0.001), second tarsometatarsal joint dorsal step-off sign by 0.8 mm (± 0.7, P<0.001), and arch height by 2.5 mm (± 6.4, P<0.048), all greater on the injured side. In the HV group, side-to-side measurements were not significantly different. There was no significant difference comparing the M1M2 measurement in the HV group with the injured (P = 0.16) or uninjured (P = 0.08) foot in the Lisfranc group. The optimal cut-off points were between the injured and uninjured foot in the Lisfranc group were 2.1 mm for C1M2 diastasis, 0.7 mm for the C2M2 alignment, and 30 mm for the C1M2 surface area. The ICC-score for the second C1M2 area measurement was 0.88.

Conclusion: Bilateral foot weightbearing radiographs can effectively diagnose ligamentous Lisfranc instability using a standardized measurement protocol. Malalignment of the medial aspect of the second metatarsal base ≥0.3 mm relatively to the intermediate cuneiform offers a high sensitivity, and distance ≥2.1 mm between the second metatarsal base and the medial cuneiform has a high specificity. Intermetatarsal distance between the first and second metatarsal base has a low sensitivity and specificity and should not be used in solitary for diagnosis.

Level Of Evidence: Level III, retrospective comparative study.
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http://dx.doi.org/10.1016/j.injury.2022.02.044DOI Listing
June 2022

Lisfranc injury: Refined diagnostic methodology using weightbearing and non-weightbearing radiographs.

Injury 2022 Jun 19;53(6):2318-2325. Epub 2022 Feb 19.

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

Background: To compare diagnostic parameters for Lisfranc instability on WB and NWB radiographs and to assess the inter-observer reliability of a standardized diagnostic protocol.

Patients And Methods: Patients who had undergone surgical treatment for subtle, purely ligamentous Lisfranc injury with both WB and NWB post-injury, pre-surgery films (n = 26) were included in this multicentre, retrospective comparative study. Also included was a control group (n = 26) of patients with isolated fifth metatarsal avulsion fractures who similarly had both WB and NWB films. Multiple midfoot distance and alignment measurements were used to evaluate the Lisfranc joint on both WB and NWB views. To evaluate interobserver reliability, measurements were made by two independent observers across a cohort subset.

Results: When comparing the NWB views between groups, only C1M2 (medial cuneiform- second metatarsal) distance was found to be significantly larger (∆ = 1.35 mm, p <0.001) for Lisfranc injuries. Most notably, C2M2 (Intermediate cuneiform - second metatarsal) step off-caused by lateral translation of the second metatarsal base-was not significantly different (∆ = 0.39 mm, p = 0.101) between Lisfranc patients and controls. On WB views, Lisfranc patients had significantly larger changes to C1M2 distance and C2M2 step-off as compared to controls (∆ = 2.97 mm, p <0.001 and ∆ =  1.98 mm, p <0.001 respectively). M1M2 (first to second intermetatarsal) distance was not significantly different between patients and controls in WB films. Within the cohort of ligamentous Lisfranc patients, C1M2 distance and C2M2 step-off were significantly larger in WB when compared to NWB films (∆ =  1.77 mm, p <0.001 and ∆ =  1.58 mm, p <0.001 respectively). For these parameters, inter-observer reliability scores (ICC) of >0. 90 were found when interpreting WB radiographs and ICC's ranging between 0.61 and 0.80 were found when interpreting NWB radiographs.

Conclusion: Using WB imaging for diagnosing subtle Lisfranc instability reveals larger diastasis in the tarsometatarsal joint and has a higher interobserver reliability compared to NWB imaging. Clinical concern for subtle or occult Lisfranc instability in any patient should therefore trigger WB radiographic assessment since such injuries may be missed on NWB views.
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http://dx.doi.org/10.1016/j.injury.2022.02.040DOI Listing
June 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

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

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

Response to the "Letter to the editor" regarding the article: "Screw versus suture button in treatment of syndesmosis instability: Comparison using weightbearing CT scan.

Foot Ankle Surg 2021 12 16;27(8):947-948. Epub 2021 Oct 16.

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

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http://dx.doi.org/10.1016/j.fas.2021.10.010DOI Listing
December 2021

Validation of PROMIS Physical Function for Evaluating Outcome After Acute Achilles Tendon Rupture.

Orthop J Sports Med 2021 Oct 18;9(10):23259671211022686. Epub 2021 Oct 18.

Department of Orthopedic Surgery, Harvard Medical School Orthopedic Trauma Initiative, Massachusetts General Hospital, Boston, Massachusetts, USA.

Background: There is increased demand for valid, reliable, and responsive patient-reported outcome measures (PROMs) to evaluate treatment for Achilles tendon rupture, but not all PROMs currently in use are reliable and responsive for this condition.

Purpose: To evaluate the measurement properties of the Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS PF) compared with other PROMs used after treatment for acute Achilles tendon rupture.

Study Design: Cohort study (diagnosis); Level of evidence, 2.

Methods: A retrospective cohort study with a follow-up questionnaire was performed. All adult patients with an acute Achilles tendon rupture between June 2016 and June 2018 with a minimum 12-month follow-up were eligible for inclusion. Functional outcome was assessed using the PROMIS PF computerized adaptive test (CAT), Foot and Ankle Ability Measure (FAAM) Activities of Daily Living (ADL), FAAM-Sports, and Achilles Tendon Total Rupture Score (ATRS). Pearson correlation () was used to assess the correlations between PROMs. Absolute and relative floor and ceiling effects were calculated.

Results: In total, 103 patients were included (mean age, 44.7 years; 74% male); 82 patients (79.6%) underwent operative repair, while 21 patients (20.4%) underwent nonoperative management. The mean time between treatment and collection of PROMs was 25.3 months (range, 15-36 months). The mean scores were 55.4 ± 9.2 (PROMIS PF), 92.9 ± 12.2 (FAAM-ADL), 77.7 ± 22.9 (FAAM-Sports), and 83.0 ± 19.4 (ATRS). The ATRS was correlated with FAAM-ADL ( = 0.80; 95% CI, 0.72-0.86; < .001) and FAAM-Sports ( = 0.86; 95% CI, 0.80-0.90; < .001). The PROMIS PF was correlated with the FAAM-ADL ( = 0.66; 95% CI, 0.53-0.75; < .001), FAAM-Sports ( = 0.65; 95% CI, 0.53-0.75; < .001), and ATRS ( = 0.69; 95% CI, 0.58-0.78; < .001). The PROMIS PF did not show absolute floor or ceiling effects (0%). The FAAM-ADL (35.9%), FAAM-Sports (15.8%), and ATRS (20.4%) had substantial absolute ceiling effects.

Conclusion: The PROMIS PF, FAAM-ADL, and FAAM-Sports all showed a moderate to high mutual correlation with the ATRS. Only the PROMIS PF avoided substantial floor and ceiling effects. The results suggest that the PROMIS PF CAT is a valid, reliable, and perhaps the most responsive tool to evaluate patient outcomes after treatment for an Achilles tendon rupture.
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http://dx.doi.org/10.1177/23259671211022686DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8527582PMC
October 2021

The Syndesmosis, Part II: Surgical Treatment Strategies.

Orthop Clin North Am 2021 Oct 30;52(4):417-432. Epub 2021 Jul 30.

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

Syndesmotic injuries in the setting of ankle fracture are critically important to diagnosis and treat to restore an anatomic tibiotalar relationship. Physical examination and clinical suspicion remain critically important for diagnosis. Ultrasound examination and weight-bearing computed tomography scans are evolving to help diagnosis more subtle injuries. Although flexible syndesmotic fixation may decrease malreduction rates, the benefits over rigid fixation is the subject of ongoing study. Anatomic reduction remains critical regardless of fixation choice. Routine removal of rigid syndesmotic hardware does not seem to offer substantial clinical improvement in pain or range of motion; however, broken hardware may cause irritation.
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http://dx.doi.org/10.1016/j.ocl.2021.05.011DOI Listing
October 2021

The Syndesmosis, Part I: Anatomy, Injury Mechanism, Classification, and Diagnosis.

Orthop Clin North Am 2021 Oct 29;52(4):403-415. Epub 2021 Jul 29.

Foot & Ankle Research and Innovation Laboratory - Harvard Medical School, Division of Foot and Ankle Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital - Newton-Wellesley Hospital, 40 2nd Avenue Building 52, Suite 1150, Waltham, MA 02451, USA; Foot & Ankle Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, 40 2nd Avenue Building 52, Suite 1150, Waltham, MA 02451, USA. Electronic address:

Ankle fractures are common injuries to the lower extremity with approximately 20% sustaining a concomitant injury to the syndesmosis. Although the deltoid ligament is not formally included in the syndesmotic complex, it plays an important role in the mortise stability. Therefore, its integrity should be always evaluated when syndesmotic injury is suspected. Given the anatomic variability of the syndesmosis between individuals, bilateral ankle imaging is recommended, especially in cases of subtle instability. Diagnostic tests that allow dynamic assessment of the distal tibiofibular joint in the 3 planes are the most reliable in determining the presence of syndesmotic injury.
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http://dx.doi.org/10.1016/j.ocl.2021.05.010DOI Listing
October 2021

Diagnosis and Treatment of Syndesmotic Unstable Injuries: Where We Are Now and Where We Are Headed.

J Am Acad Orthop Surg 2021 Dec;29(23):985-997

From the Foot & Ankle Research and Innovation Laboratory (Bejarano-Pineda, DiGiovanni, Waryasz, and Guss), Harvard Medical School, Massachusetts General Hospital; Foot & Ankle Service (Bejarano-Pineda, DiGiovanni, Waryasz, and Guss), Department of Orthopaedic Surgery, Massachusetts General Hospital; Newton-Wellesley Hospital (Bejarano-Pineda, DiGiovanni, Waryasz, and Guss), Harvard Medical School, Massachusetts General Hospital, Boston.

Up to 10% of ankle sprains are considered "high ankle" sprains with associated syndesmotic injury. Initial diagnosis of syndesmotic injury is based on physical examination, but further evaluation of the distal tibiofibular joint in the sagittal, coronal, and rotational planes is necessary to determine instability. Imaging modalities including weight-bearing CT and ultrasonography allow a physiologic and dynamic assessment of the syndesmosis. These modalities in turn provide the clinician useful information in two and three dimensions to identify and consequently treat syndesmotic instability, especially when subtle. Because there is notable variability in the shape of the incisura between individuals, contralateral comparison with the uninjured ankle as an optimal internal control is advised. Once syndesmotic instability is identified, surgical treatment is recommended. Several fixation methods have been described, but the foremost aspect is to achieve an anatomic reduction. Identifying any associated injuries and characteristics of the syndesmotic instability will lead to the appropriate treatment that restores the anatomy and stability of the distal tibiofibular joint.
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http://dx.doi.org/10.5435/JAAOS-D-20-01350DOI Listing
December 2021

Surgical Management of Musculotendinous Balance in the Progressive Collapsing Foot Deformity: The Role of Peroneal and Gastrocnemius Contracture.

Foot Ankle Clin 2021 Sep;26(3):559-575

Department of Orthopaedic Surgery, Foot and Ankle Service, Harvard Medical School, Massachusetts General Hospital and Newton-Wellesley Hospital, MGH-NWH Foot & Ankle Center, Building 52, Suite 1150, 40 2nd Avenue, Waltham, MA 02451, USA.

Surgical treatment of progressive collapsing foot deformity (PCFD) relies on understanding the dynamic and deforming musculotendinous structures that contribute to hindfoot valgus, forefoot abduction, forefoot varus, and collapse or hypermobility of the medial column. Equinus commonly is seen in PCFD and consideration should be given to isolated gastrocnemius or Achilles lengthening. Although transfer of the flexor digitorum longus tendon is performed in PCFD attributed to dysfunction and pathology of the posterior tibialis tendon (PTT), retention of PTT is an area for further research. The peroneus brevis, which contributes to hindfoot imbalance in chronic cases, is a possible component of tendon rebalancing.
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http://dx.doi.org/10.1016/j.fcl.2021.06.005DOI Listing
September 2021

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

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

Screw versus suture button in treatment of syndesmosis instability: Comparison using weightbearing CT scan.

Foot Ankle Surg 2021 Apr 5;27(3):285-290. Epub 2021 Jan 5.

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

Background: The superiority of screw or suture button fixation for syndesmotic instability remains debatable. Our aim is to compare radiographic outcomes of screw and suture button fixation of syndesmotic instability using weight bearing CT scan (WBCT).

Methods: Twenty patients with fixation of unilateral syndesmotic instability were recruited and divided among two groups (screw = 10, suture button = 10). All patients had WBCT of both ankles ≥12 months postoperatively.

Results: In suture button group, injured side measurements were significantly different from normal side for syndesmotic area (P = 0.003), fibular rotation (P = 0.004), anterior difference (P = 0.025) and direct anterior difference (P = 0.035). In screw group, syndesmotic area was the only significantly different measurement (P = 0.006).

Conclusion: While both screw and suture button didn't completely restore the syndesmotic area as compared to the contralateral uninjured ankle, external malrotation of the fibula was uniquely associated with suture button fixation.

Level Of Evidence: III Retrospective Cohort Study.
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http://dx.doi.org/10.1016/j.fas.2021.01.001DOI Listing
April 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

Diagnosis and Treatment of Chronic Lateral Ankle Instability: Review of Our Biomechanical Evidence.

J Am Acad Orthop Surg 2021 Jan;29(1):3-16

From the Foot and Ankle Research and Innovation Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Chang, Saengsin), the Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Japan (Chang), the Foot & Ankle Service, Department of Orthopaedic Surgery, Massachusetts General Hospital (Morris, Guss, DiGiovanni), the Massachusetts General Hospital, Newton- Wellesley Hospital, Harvard Medical School, Boston, MA (Morris, Guss, DiGiovanni), the Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand (Saengsin), the Foot and Ankle Institute of Grenoble, Centre Ostéo Articulaire des Cèdres, Echirolles (Tourné), and the Sport's Medical Clinic of Bordeaux, Bordeaux-Mérignac, France (Guillo).

Definitive diagnosis and optimal surgical treatment of chronic lateral ankle instability remains controversial. This review distills available biomechanical evidence as it pertains to the clinical assessment, imaging work up, and surgical treatment of lateral ankle instability. Current data suggest that accurate assessment of ligament integrity during physical examination requires the ankle to ideally be held in 16° of plantar flexion when performing the anterior drawer test and 18° of dorsiflexion when performing the talar tilt test, respectively. Stress radiographs are limited by their low sensitivity, and MRI is limited by its static nature. Surgically, both arthroscopic and open repair techniques appear biomechanically equivalent in their ability to restore ankle stability, although sufficient evidence is still lacking for any particular procedure to be considered a superior construct. When performing reconstruction, grafts should be tensioned at 10 N and use of nonabsorbable augmentations lacking viscoelastic creep must factor in the potential for overtensioning. Anatomic lateral ligament surgery provides sufficient biomechanical strength to safely enable immediate postoperative weight bearing if lateral ankle stress is neutralized with a boot. Further research and comparative clinical trials will be necessary to define which of these ever-increasing procedural options actually optimizes patient outcome for chronic lateral ankle instability.
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http://dx.doi.org/10.5435/JAAOS-D-20-00145DOI Listing
January 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

Isolated Intermetatarsal Ligament Release as Primary Operative Management for Morton's Neuroma: Short-term Results.

Foot Ankle Spec 2022 Aug 19;15(4):338-345. Epub 2020 Sep 19.

Foot and Ankle Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (MAE, GRW, KCW).

Background: Although the precise pathoetiology of Morton's neuroma remains unclear, chronic nerve entrapment from the overlying intermetatarsal ligament (IML) may play a role. Traditional operative management entails neuroma excision but risks unpredictable formation of stump neuroma.

Materials And Methods: Medical records were examined for adult patients who failed at least 3 months of conservative treatment for symptomatic and recalcitrant Morton's neuroma and who then underwent isolated IML decompression without neuroma resection.

Results: A total of 12 patients underwent isolated IML decompression for Morton's neuroma with an average follow-up of 13.5 months. Visual Analog Pain Scale averaged 6.4 ± 1.8 (4-9) preoperatively and decreased to an average of 2 ± 2.1 (0-7) at final follow-up (P = .002). All patients reported significant improvement.

Conclusion: Isolated IML release of chronically symptomatic Morton's neuroma shows promising short-term results regarding pain relief, with no demonstrated risk of recurrent neuroma formation, permanent numbness, or postoperative symptom exacerbation.

Level Of Evidence: .
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http://dx.doi.org/10.1177/1938640020957851DOI Listing
August 2022

Fusion Versus Joint-Sparing Reconstruction for Patients With Flexible Flatfoot.

Foot Ankle Spec 2022 Apr 24;15(2):150-157. Epub 2020 Aug 24.

School of Medicine, Georgetown University, Washington, DC (KW).

Aims: Passively correctible, adult-acquired flatfoot deformities (AAFD) are treated with joint-sparing procedures. Questions remain as to the efficacy of such procedures when clinical deformities are severe. In severe deformities, a primary fusion may lead to predictable outcomes, but risks nonunion. We evaluated pre- and postsurgical flexible AAFD patients undergoing joint-sparing or fusion procedures, comparing reoperation and complication rates.

Methods: We identified patients with flexible AAFD between January 1, 2001 and 2016. Exclusion criteria were incomplete medical record, rigid AAFD, and prior flatfoot surgery. Patient demographics, pre- and postsurgical radiographic measurements, surgery performed, and postoperative complications were evaluated by bivariate analysis, comparing joint-sparing versus fusion procedures.

Results: Of 239 patients (255 feet) (mean follow-up 62 ± 50 months), 209 (87%) underwent joint-sparing reconstructions, 30 (12.6%) underwent fusions. Fifty-four (24.1%) feet underwent joint-sparing reconstruction with reoperation versus 11 (35.5%) in fusion patients ( = .17). Radiographic improvement in talonavicular angle, talar first-metatarsal (anteroposterior view), and Meary's angle was higher in fusion patients ( < .001, < .001, and = .003, respectively).

Discussion: More nonunion reoperations among fusion patients were offset by reoperations in joint-sparing patients. Fusion uniquely corrected Meary's angle. Nonunion is of less concern for joint-sparing versus fusion for patients with severe flexible AAFD. Degree of deformity versus advantage of joint motion should improve decision making.

Levels Of Evidence: Level IV: Retrospective case series.
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http://dx.doi.org/10.1177/1938640020950552DOI Listing
April 2022

The Effect of Gastrocnemius Recession and Tendo-Achilles Lengthening on Adult Acquired Flatfoot Deformity Surgery: A Systematic Review.

J Foot Ankle Surg 2020 Nov - Dec;59(6):1248-1253. Epub 2020 Aug 20.

Associate Professor, Massachusetts General Hospital and Newton-Wellesley Hospital, Harvard Medical School, Boston, MA.

The purpose of this study was to evaluate the available clinical and radiographic evidence for incorporation of a gastrocnemius recession or tendo-Achilles lengthening into the surgical correction of adult acquired flatfoot deformity. A systematic review of the literature was performed using PubMed, Embase, Cochrane, CINAHL, and Google Scholar. Among the relevant articles, the level of evidence and quality was identified using the Methodological Index for Non-Randomized Studies tool. No study explicitly examined whether clinical or radiographic outcomes after adult acquired flatfoot deformity correction are improved when incorporating a gastrocnemius recession or tendo-Achilles lengthening compared with when no such procedure is performed, nor have they directly compared outcomes between 2 procedures. Studies demonstrated an overall improvement in postoperative range of motion and plantar flexion power after gastrocnemius recession, but such findings are hard to separate from the clinical contribution of concomitant corrective procedures to the foot itself. All studies that analyzed anteroposterior talo-calcaneal angle, anteroposterior lateral talo-first metatarsal angle and calcaneal inclination angle revealed improvement of each parameter postoperatively. There were no high-level evidence studies in the literature explicitly quantifying ankle range of motion, plantar flexion power, or radiographic impact of gastrocnemius recession or tendo-Achilles lengthening on adult acquired flatfoot deformity correction. Although gastrocnemius-soleus complex contractures have certainly been demonstrated to coexist with adult acquired flatfoot deformity, support for lengthening procedures is largely based on expert opinion or case series and is difficult to distinguish from the clinical contribution of associated corrective procedures.
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http://dx.doi.org/10.1053/j.jfas.2020.03.016DOI Listing
June 2021

Arthroscopic coronal plane syndesmotic instability has been over-diagnosed.

Knee Surg Sports Traumatol Arthrosc 2021 Jan 25;29(1):310-323. Epub 2020 May 25.

Department of Orthopaedic Surgery, Amsterdam University Medical Center, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam Zuidoost, The Netherlands.

Purpose: Ankle arthroscopy is widely used for diagnosis of syndesmotic instability, especially in subtle cases. To date, no published article has systematically reviewed the literature in aggregate to understand which instability values should be used intraoperatively. The primary aim was to systematically review the amount of tibiofibular displacement that correlates with syndesmotic instability after a high ankle sprain. A secondary aim is to assess the quality of such research.

Methods: Systematic searches of EMBASE (Ovid) and MEDLINE via PubMed, CINAHL, Web of Science, and Google Scholar were used.

Inclusion Criteria: studies that arthroscopically evaluated the fibular displacement at various stages of syndesmotic ligament injury. Two reviewers independently extracted data and assessed methodological quality using the Anatomical Quality Assessment (AQUA) Tool and methodological index for non-randomized studies (MINORS).

Results: Eight cadaveric studies and three clinical studies were included for review. All studies reported displacement in the coronal plane, four studies reported in the sagittal plane, and one reported findings in the rotational plane. Four cadaveric studies had a similar experimental set up and the weighted mean associated with instability in the coronal plane could be calculated and was 2.9 mm at the anterior portion of the distal tibiofibular joint and 3.4 mm at the posterior portion. Syndesmotic instability in the sagittal plane is less extensively studied, however available data from a cadaveric study suggests thresholds of 2.2 mm of posterior fibular translation when performing an anterior to posterior hook test and 2.6 mm of anterior fibular translation when performing a posterior to anterior hook test.

Conclusions: The results have concluded that the commonly used 2.0 mm threshold value of distal tibiofibular diastasis may lead to overtreatment of syndesmotic instability, and that using threshold values of 2.9 mm measured at the anterior portion of the incisura and 3.4 mm at the posterior portion may represent better cut off values. Given the ready availability of 3 mm probes among standard arthroscopic instrumentation, at the very least surgeons should use 3 mm in lieu of 2 mm probes intraoperatively.

Level Of Evidence: IV.
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http://dx.doi.org/10.1007/s00167-020-06067-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7862212PMC
January 2021

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

Tibial Stress Fracture Following Ankle Arthrodesis.

Foot Ankle Int 2020 05 17;41(5):556-561. Epub 2020 Feb 17.

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

Background: End-stage ankle arthritis is frequently treated with either tibiotalar or tibiotalocalcaneal (TTC) arthrodesis, but the inherent loss of accommodative motion increases mechanical load across the distal tibia. Rarely, patients can go on to develop a stress fracture of the distal tibia without any antecedent traumatic event. The purpose of this study was to determine the incidence of tibial stress fracture after ankle arthrodesis, highlight any related risk factors, and identify the effectiveness of treatment strategies and their healing potential.

Methods: A retrospective chart review was performed at 2 large academic medical centers to identify patients who had undergone ankle arthrodesis and subsequently developed a stress fracture of the tibia. Any patient with a tibial stress fracture before ankle arthrodesis, or with a nontibial stress fracture, was excluded from the study.

Results: A total of 15 out of 1046 ankle fusion patients (1.4%) developed a tibial stress fracture at a mean time of 42 ± 82 months (range, 3-300 months) following the index procedure. The index procedure for these 15 patients who went on to subsequently develop stress fractures included isolated ankle arthrodesis (n = 8), ankle arthrodesis after successful subtalar fusion (n = 2), primary TTC arthrodesis (n = 2), and ankle arthrodesis subsequent to successful subtalar fusion with resultant ankle nonunion requiring revision TTC nailing (n = 3). Four patients had undergone fibular osteotomy with subsequent onlay strut fusion, and 5 had undergone complete resection of the lateral malleolus. Stress fracture location was found to be at the level of the fibular osteotomy in 2 patients and at the proximal end of an existing or removed implant in 9. Fourteen of the 15 patients had a nondisplaced stress fracture and were initially treated with immobilization and activity modification. Of these, 3 failed to improve with nonoperative treatment and subsequently underwent operative fixation (intramedullary nail in 2; plate fixation in 1). Only 1 of the 15 patients presented with a displaced fracture and underwent immediate plate fixation. All patients reported pain improvement and were ultimately healed at final follow-up.

Conclusion: In this case series review, we found a 1.4% incidence of tibial stress fracture after ankle arthrodesis, and both hardware transition points and a fibular resection or osteotomy appear to be risk factors. Operative intervention was required in approximately 25% of this population, but the majority of tibial stress fractures following ankle fusion were successfully treated nonoperatively, and ultimately all healed.

Level Of Evidence: Level IV, retrospective case series.
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http://dx.doi.org/10.1177/1071100720907595DOI Listing
May 2020
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