Publications by authors named "George T Liu"

23 Publications

  • Page 1 of 1

Insulin Dependence Increases the Risk of 30-Day Postoperative Complications Following Ankle Fracture Surgery in Patients With Diabetes Mellitus.

J Foot Ankle Surg 2021 Mar 20. Epub 2021 Mar 20.

Associate Professor, Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX. Electronic address:

Patients with diabetes mellitus that undergo ankle fracture surgery have higher rates of postoperative complications compared to patients without diabetes mellitus. We evaluated the rate of complications in insulin-dependent diabetes mellitus patients, non-insulin-dependent diabetes mellitus patients, and patients without diabetes in the 30-day postoperative period following ankle fracture surgery. We also analyzed hospital length of stay, unplanned readmission, unplanned reoperation, and death. Patients who underwent operative management for ankle fractures between 2012 and 2016 were identified in the American College of Surgeons National Surgical Quality Improvement Program® database using Current Procedural Terminology codes. Multiple logistic regression was implemented. Adjusted odds ratios were calculated along with the 95% confidence interval. A total of 19,547 patients undergoing ankle surgery were identified from 2012 to 2016. Of these patients, 989 (5.06%) had insulin-dependent diabetes mellitus, 1256 (6.43%) had noninsulin-dependent diabetes mellitus, and 17,302 (88.51%) did not have diabetes mellitus. Compared to patients without diabetes, patients with insulin-dependent diabetes mellitus had significantly greater adjusted odds of superficial surgical site infections, deep surgical site infections, osteomyelitis, wound dehiscence, pneumonia, unplanned intubation, mechanical ventilation, urinary tract infection, cardiac arrest, bleeding requiring transfusion, sepsis, hospital length of stay, unplanned readmission, unplanned reoperation, and death following ankle fracture surgery. We demonstrate that insulin-dependent diabetes mellitus is a strong predictor of 30-day postoperative complications, unplanned readmission, unplanned reoperation, and death following ankle fracture surgery.
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http://dx.doi.org/10.1053/j.jfas.2021.03.011DOI Listing
March 2021

Biomechanical Performance of Charcot-Specific Implants.

J Foot Ankle Surg 2021 May-Jun;60(3):440-447. Epub 2020 Jun 7.

Engineer, Department of Research, Development and Innovation, Orthofix Srl, Bussolengo, Italy.

Over the past 2 decades, an increased number of diabetic Charcot neuroarthropathy reconstructions have been performed. Despite advances in implant technology, arthrodesis complication rates remain high. This study examined the biomechanical properties (4-point bending, cantilever bending, and thread pullout resistance) of intramedullary implants designed for midfoot reconstruction. Large implants included A1 (7.4 mm cannulated stainless steel beam), B1 (6.5 mm solid titanium bolt), and C1 (7.0 mm cannulated titanium beam). Smaller implants included A2 (5.4 mm cannulated stainless steel beam) and C2 (5.0 mm solid titanium bolt). Four-point bending testing compared flexural properties of the body of the implants. Cantilever-bending testing was performed with the maximum bending moment being applied off the main thread of the implant to assess the thread portion. Thread pullout strength was tested by fixing the implants to a Sawbone block on a platform, and the distal portion of the implant in a clamp connected to loading actuator. Implant A1 demonstrated higher stiffness, force to failure, and fatigue compared to implants B1 and C1 (p < .05). Pullout strength of implant A1 was higher than implant B1 (p < .05). Thread fatigue strength of implant A1 was higher than implant C1 (p < .05). Implant A2 demonstrated higher stiffness, force to failure, tip fatigue strength, and thread pullout strength compared to implant C2 (p < .05), while implant C2 demonstrated higher body fatigue failure than implant A2 (p < .05). Alteration of beam/bolt parameters influences the biomechanical performance of implants used in Charcot reconstruction. Greater stiffness resists deformation, providing improved stability. Greater static failure load and fatigue limit improves the implant's ability to withstand higher and repetitive loads before failing This study should stimulate further clinical research to determine if these biomechanical properties translate into reduced implant failure rates and improved clinical outcomes in patients with diabetic Charcot neuroarthropathy.
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http://dx.doi.org/10.1053/j.jfas.2020.05.016DOI Listing
June 2020

Short Term Radiographic and Patient Outcomes of a Biplanar Plating System for Triplanar Hallux Valgus Correction.

J Foot Ankle Surg 2021 May-Jun;60(3):461-465. Epub 2020 Aug 15.

Assistant Professor, Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX. Electronic address:

Hallux valgus is a complex deformity with a variety of techniques described for correction. A biplanar plating system for triplanar correction system has been developed to address both the translation and rotational component of the hallux valgus deformity and allow an accelerated weightbearing protocol. The purpose of this study was to determine the correction and complications using radiographic parameters and patient reported outcomes. We sought to determine prognostic factors for successful correction, including age, gender, and preoperative deformity. From the medical records, we collected preoperative data. Patient-reported outcomes were obtained using AOFAS Hallux Metatarsophalangeal-Interphalangeal score, FAAM, and SF-12 scores preoperatively and postoperatively. Imaging was reviewed at preoperative and postoperative visits to determine hallux valgus angle, intermetatarsal angle, and tibial sesamoid position. Fifty-seven procedures, in 55 patients, were performed. There were 7 complications and mean follow-up time was 45.7 weeks (+ 28.3 weeks). Age over 62.5 years were associated with an increased risk of complications (p = .018). Males had an increased rate of complications (71%) compared with females. Radiographic parameters were significantly improved from preoperative values at alltime points (p < .05). Only the AOFAS Hallux Metatarsophalangeal-Interphalangeal score was statistically significant at 3, 6 and 12 months. We sought to determine the effectiveness of biplanar plating and triplanar correction procedure with early weightbearing. Over a 12 month follow-up period, our results showed significant improvement in deformity and maintained correction. AOFAS Hallux Metatarsophalangeal-Interphalangeal scores significantly improved from the preoperative to the postoperative state. Our results show a nonunion rate of 5.2%, which is comparable to prior studies.
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http://dx.doi.org/10.1053/j.jfas.2020.06.026DOI Listing
August 2020

Are the Sanders-Frykberg and Brodsky-Trepman Classifications Reliable in Diabetic Charcot Neuroarthropathy?

J Foot Ankle Surg 2021 May-Jun;60(3):432-435. Epub 2021 Feb 3.

Professor, Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX; Professor, Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX.

The purpose of this study was to assess the intra- and inter-reader reliability of the 2 Charcot neuroarthropathy classifications (Sanders-Frykberg and Brodsky-Trepman), as well as Eichenholtz staging. We hypothesized that the inter-reader reliability, with respect to these 3 classification systems, would be moderate at best. Digital radiographic images were organized in a digital slide presentation without clinical information. All 5 reviewers underwent a standard training session administered by the principal investigator, reviewing 5 cases of Charcot neuroarthropathy. Images of 55 cases of Charcot neuroarthropathy and 5 normal cases were distributed to each of the 5 physicians electronically, who independently rated all 60 cases according to the 3 classification systems. The 95% confidence interval of the intraclass correlation coefficient estimate for Sanders-Frykberg was 0.9601 to 0.9833 at week 0 and 0.9579 to 0.9814 at week 8, which can be regarded as "excellent" reliability. For Trepman-Brodsky, the 95% confidence interval of the intraclass correlation coefficient estimate was 0.8463 to 0.9327 at week 0 and 0.8129 to 0.9226 at week 8, which can be regarded as "good" to "excellent" reliability. For Eichenholtz, the 95% confidence interval of the intraclass correlation coefficient estimate was 0.6841 to 0.8640 and 0.6931 to 0.8730 at weeks 0 and 8, respectively, which can be regarded as "moderate" to "good" reliability. The classification systems of Charcot neuroarthropathy are an important tool for communication among physicians. Based on the results at our institution, the Sanders-Frykberg classification exhibited the best inter-reader performance. The Trepman-Brodsky classification exhibited good to excellent reliability as well. The intraclass correlation coefficient of the Eichenholtz classification was moderate to good.
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http://dx.doi.org/10.1053/j.jfas.2020.03.003DOI Listing
February 2021

Charcot Midfoot Reconstruction: Does Subtalar Arthrodesis or Medial Column Fixation Improve Outcomes?

J Foot Ankle Surg 2020 Nov - Dec;59(6):1219-1223. Epub 2020 Jul 18.

Assistant Professor, Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX. Electronic address:

Charcot neuroarthropathy is a complication of neuropathy often secondary to diabetes mellitus and most commonly affects the midfoot. In these patients, reconstruction of the foot may be required for limb salvage. A superconstruct technique has previously been described using intramedullary beaming fixation of the midfoot and hindfoot to span the zone of injury. Inclusion of the subtalar joint in the arthrodesis construct is not consistently performed among different surgeons. The aim of this study was to describe midfoot beaming constructs and postoperative complications after midfoot reconstruction with and without subtalar arthrodesis. We reviewed medical records of patients who underwent midfoot Charcot reconstruction with an intramedullary beaming superconstruct. Patients included in the study had at least 3 months of follow-up and had Sanders-Frykberg II/III classification of Charcot neuroarthropathy. Postoperative radiographs were evaluated for evidence of hardware failure at the latest follow-up evaluation. The main variables of interest were: hardware failure or nonunion requiring revision operation, deep infection, and unplanned reoperation. Thirty patients who underwent midfoot reconstruction were included. The mean follow-up was 67.4 ± 25.9 weeks. Twenty-two (73.3%) patients had concomitant subtalar arthrodesis and midfoot beaming. Overall complications were lower in patients with subtalar arthrodesis (40.9%) than those without subtalar arthrodesis (75%) resulting in an odds ratio of 0.271 (0.042-1.338, p = .146). Furthermore, increased number of screws used in the midfoot construct was negatively correlated with complications (r = -0.44, p = .01). An intramedullary midfoot beaming superconstruct with subtalar arthrodesis has previously been proposed to provide better fixation after midfoot beaming Charcot neuroarthropathy reconstruction. Our results suggest including the subtalar joint as part of a superconstruct for the reconstruction of Sanders-Frykberg II/III Charcot results in an 80% lower complication rate than intramedullary beaming alone. We also found an increased number of screws used in the midfoot results in a lower complication rate.
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http://dx.doi.org/10.1053/j.jfas.2020.07.001DOI Listing
July 2020

Charcot Reconstruction: Outcomes in Patients With and Without Diabetes.

J Foot Ankle Surg 2020 Nov - Dec;59(6):1229-1233. Epub 2020 Aug 7.

Attending Physician, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC.

The objective of this study is to compare risk adjusted matched cohorts of Charcot neuroarthropathy patients who underwent osseous reconstruction with and without diabetes. The 2 groups were matched based on age, body mass index, hypertension, history of end-stage renal disease, and peripheral arterial disease. Bivariate analysis was performed for preoperative infection, location of Charcot breakdown, and post reconstruction outcomes, in patients with a minimum of 1 year follow-up period. Through bivariate analysis, presence of preoperative ulceration (p = .0499) was found to be statistically more likely in the patients with diabetes; whereas, delayed osseous union (p = .0050) and return to ambulation (p ≤ .0001) was statistically more likely in patients without diabetes. The nondiabetic Charcot patients were 17.6 folds more likely to return to ambulation (odds ratio [OR] 17.6 [95% confidence interval {CI} {3.5-87.6}]), and 16.4 folds more likely to have delayed union (OR 16.4 [95% CI {1.9-139.6)]). Subanalysis compared well-controlled diabetic and nondiabetic Charcot neuroarthropathy patients for same factors. Multivariate analysis, in the subanalysis, found return to ambulation was 15.1 times likely to occur in the nondiabetic CN cohort (OR 15.1 [95% CI 1.3-175.8]) compared to the well-controlled diabetic CN cohort.
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http://dx.doi.org/10.1053/j.jfas.2020.05.019DOI Listing
August 2020

Trauma in the Diabetic Limb.

Clin Podiatr Med Surg 2019 Jul 8;36(3):499-523. Epub 2019 Apr 8.

Orthopaedic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390-8883, USA; Foot and Ankle Service, Orthopaedic Surgery, Parkland Memorial Hospital, Level 1 Trauma Center, 5200 Harry Hines Boulevard, Dallas, TX 75235, USA.

Poorly controlled diabetes with comorbid manifestations negatively affects outcomes in lower extremity trauma, increasing the risk of short-term and long-term complications. Management strategies of patients with diabetes that experience lower extremity trauma should also include perioperative management of hyperglycemia to reduce adverse and serious adverse events.
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http://dx.doi.org/10.1016/j.cpm.2019.02.012DOI Listing
July 2019

Optimizing Results in Diabetic Charcot Reconstruction.

Clin Podiatr Med Surg 2019 Jul 11;36(3):469-481. Epub 2019 Apr 11.

Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390, USA.

Reconstruction of the diabetic Charcot foot can be a challenge even for the most experienced foot and ankle surgeon. The first portion of this article discusses the preoperative evaluation with an emphasis on factors that can be modified before surgical reconstruction to help optimize surgical results. The second portion of the article focuses on intraoperative methods and techniques to help improve postoperative outcomes. Surgeons should strive to provide high-quality, cost-effective care by optimizing patient selection and perioperative care. Objective measures of patient outcomes will become increasingly important with the transition from volume-based to value-based care.
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http://dx.doi.org/10.1016/j.cpm.2019.02.010DOI Listing
July 2019

Lower Extremity Necrotizing Fasciitis in Diabetic and Nondiabetic Patients: Mortality and Amputation.

Int J Low Extrem Wounds 2019 Jun 1;18(2):114-121. Epub 2019 Apr 1.

1 University of Texas Southwestern Medical Center, Dallas, TX, USA.

Lower extremity necrotizing fasciitis (NF) is a severe infection requiring immediate surgery. The aim of this study was to assess patient factors predictive of amputation and mortality in diabetes mellitus (DM) and non-DM patients with lower extremity NF. The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database was reviewed retrospectively. Out of 674 patients with lower extremity NF, 387 had DM (57.4%). Patients with DM had lower mortality ( = .004). Increased mortality was independently associated with age >60 years (adjusted odds ratio [aOR] = 3.96, 95% confidence interval [CI] = 1.69-9.77), partial thromboplastin time >38 seconds (aOR = 2.66, 95% CI = 1.09-6.62), albumin <2.0 mg/dL (aOR = 2.84, 95% CI = 1.13-7.37), coagulopathy (aOR = 3.29, 95% CI = 1.24-9.19), higher anesthesia risk category (aOR = 3.08, 95% CI = 1.18, 8.59), chronic obstructive pulmonary disease (aOR = 3.46, 95% CI = 1.13-10.9), postoperative acute respiratory distress syndrome (aOR = 5.24, 95% CI = 2.04-14.4), and postoperative septic shock (aOR = 5.14, 95% CI = 1.94-14.1). Amputation was independently associated with DM (aOR = 4.35, 95% CI = 2.63-7.35) but not mortality. Although DM was associated with more amputations for lower extremity NF, patients with DM had lower mortality than non-DM patients in the bivariate analysis. Further research is needed to investigate outcomes among DM and non-DM patients in the context of lower extremity NF.
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http://dx.doi.org/10.1177/1534734619836464DOI Listing
June 2019

Is Routine Hardware Removal Following Open Reduction Internal Fixation of Tarsometatarsal Joint Fracture/Dislocation Necessary?

J Foot Ankle Surg 2019 Mar;58(2):226-230

Associate Professor, Department of Orthopedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX.

Open reduction internal fixation (ORIF) is an accepted treatment for displaced tarsometatarsal joint (TMTJ) fracture dislocations. In general, hardware is routinely removed after 4 months to allow restoration of joint motion and avoid complications of hardware failure. Because few studies report outcomes of TMTJ fractures with retained hardware, there is little consensus regarding the optimal time for hardware removal or if hardware retention leads to adverse outcomes. We retrospectively reviewed the radiographic outcomes of retained hardware after ORIF of TMTJ fractures/dislocations in 61 patients. The mean age at the time of operation was 37.3 ± 14.9 years. ORIF was performed with 3.5 fully threaded cortical screws. Assessment of clinical and radiographic results was performed at 2 weeks, 6 weeks, 3 months, 6 months, and 12 months after surgical treatment. Out of the 61 patients that were included in this study, only 2 demographic variables demonstrated a trend for an adverse outcome. Older age correlated with lost reduction and elevated body mass index correlated with hardware failure. The presence of diabetes was correlated with an increased risk of postoperative infection but not hardware failure. During our follow-up period there were 49 patients (80.3 %) without failure of fixation. In conclusion, our study suggests that routine removal of hardware following open reduction and internal fixation of Lisfranc injuries in patients may not be necessary.
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http://dx.doi.org/10.1053/j.jfas.2018.08.016DOI Listing
March 2019

Surgical Management of Displaced Intra-Articular Calcaneal Fractures: What Matters Most?

Clin Podiatr Med Surg 2019 Apr 24;36(2):173-184. Epub 2019 Jan 24.

Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390-8883, USA.

Displaced intra-articular calcaneal fractures are severe, complex injuries that can cause significant long-term functional impairment. Despite the controversies of whether these fractures should be treated operatively or nonoperatively, functional improvement can be seen with confounding variables that can be controlled by the surgeon. This article reviews prognostic factors that are associated with good functional outcomes following operatively treated displaced intra-articular calcaneal fractures.
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http://dx.doi.org/10.1016/j.cpm.2018.10.002DOI Listing
April 2019

Increased Rates of Readmission, Reoperation, and Mortality Following Open Reduction and Internal Fixation of Ankle Fractures Are Associated With Diabetes Mellitus.

J Foot Ankle Surg 2019 May 11;58(3):470-474. Epub 2019 Feb 11.

Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX. Electronic address:

The purpose of this study was to compare the rates of readmission, reoperation, and mortality in patients with and without diabetes mellitus during the 30-day postoperative period after ankle fracture surgery. Patients who underwent operative management for ankle fractures between 2006 and 2015 were identified in the American College of Surgeons National Surgical Quality Improvement Program database by using Current Procedural Terminology codes for ankle fracture surgery. A total of 17,464 patients undergoing ankle fracture surgery were identified. Of these patients, 2044 (11.7%) had diabetes and 15,420 (88.3%) did not have diabetes. We excluded patients older than 90 years or with inadequate perioperative data. Patients with diabetes had significantly higher rates of readmission (2.84% vs 1.05%, p < .0001), significantly higher rates of unplanned reoperation (2.3% vs 0.74%, p < .0001), and significantly higher rates of mortality (0.7% vs 0.2%, p < .0001) compared with patients without diabetes. Additionally, patients with diabetes had significantly greater age-adjusted odds ratios (ORs) of unplanned readmission (OR 2.40, 95% confidence interval [CI] 1.74 to 3.31, p < .0001), unplanned reoperation (OR 2.56, 95% CI 1.44 to 3.27, p < .0001), and mortality (OR 2.01, 95% CI 1.08 to 3.62, p = .0432) than did patients without diabetes after ankle surgery. In this large-scale retrospective study, we demonstrated that the presence of diabetes significantly increases the risk of unplanned readmission, unplanned reoperation, and mortality during the 30-day postoperative period after ankle fracture surgery.
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http://dx.doi.org/10.1053/j.jfas.2018.09.023DOI Listing
May 2019

Renal Function as a Predictor of Early Transmetatarsal Amputation Failure.

Foot Ankle Spec 2019 Oct 12;12(5):439-451. Epub 2018 Dec 12.

Department of Orthopaedic Surgery (JA, KMR, GTL, DKW), University of Texas Southwestern Medical Center, Dallas, Texas.

Chronic kidney disease (CKD) is a major concern in patients with foot disease because it is associated with high rates of neuropathy, peripheral vascular disease, and poor wound healing. The purpose of this study was to evaluate renal dysfunction as a risk factor for reamputation after initial transmetatarsal amputation (TMA). Patients who underwent a TMA were retrospectively identified in the American College of Surgeons National Surgical Quality Improvement Program database. Of 2018 patients, reamputation after TMA occurred in 4.4%. End-stage renal disease (ESRD) was associated with 100% increased odds of TMA failure (adjusted odds ratio [OR] = 2.00; 95% CI = 1.10, 3.52), 128% increased odds of major amputation (adjusted OR = 2.28; 95% CI = 1.27, 3.96), and 182% increased odds of 30-day mortality (adjusted OR = 2.82; 95% CI = 1.69, 4.64). In addition, white blood cell count >10 000/mm and deep infection at the time of surgery were independently associated with TMA failure. In conclusion, severe renal dysfunction is associated with TMA failure in the short-term, perioperative period. There was no incremental increase in risk of TMA failure with worsening level of renal function before ESRD. A multidisciplinary approach should be implemented in patients with CKD to prevent foot-related pathologies that may necessitate lower-extremity amputation. : .
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http://dx.doi.org/10.1177/1938640018816371DOI Listing
October 2019

Three-Dimensional Computed Tomographic Characterization of Normal Anatomic Morphology and Variations of the Distal Tibiofibular Syndesmosis.

J Foot Ankle Surg 2018 Nov - Dec;57(6):1130-1136. Epub 2018 Sep 7.

Associate Professor, Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX; Assistant Professor, Radiology, University of Texas Southwestern Medical Center, Dallas, TX.

Malreduction of distal tibiofibular syndesmosis (DTFS) leads to poor functional outcomes after ankle fracture surgery. Difficulty achieving anatomic alignment of the syndesmosis is due to variable morphology of the fibular incisura of the tibia and a paucity of literature regarding its morphologic characteristics. We surveyed 775 consecutive ankle computed tomography (CT) scans performed from June 2008 to December 2011, and 203 (26.2%) were included for evaluation. Two observers performed quantitative measurements and qualitative evaluated fibular incisura morphology. Tang ratios for fibular rotation, anterior and posterior tibiofibular distances, fibular incisura depth, and subjective morphologies on CT were assessed using conventional multiplanar reconstruction (MPR) and maximum intensity projections (MIPs). On conventional CT, the mean Tang ratio was 0.97 ± 0.06; the mean anterior tibiofibular distance was 2.17 ± 0.87 mm; the mean posterior tibiofibular distance was 3.52 ± 0.94 mm; and the mean depth of fibular incisura was 3.29 ± 1.19 mm. Five morphologic variations of the fibular incisura were identified: crescentic, trapezoid, flat, chevron, and widow's peak. The most common fibular incisura morphology was crescentic (61.3%), followed by trapezoid shape (25.1%); the least common morphology was flat (3.1%). Interobserver variability with intraclass correlation coefficient (ICC) was slightly higher for all quantitative measures on MPR (ICC = 0.72 to .81) versus MIP (ICC = 0.64 to 0.75). ICC for incisura shape and depth assessments was poor on both modalities (0.13 to 0.38). This comprehensive CT study reports on quantitative and qualitative descriptive measures to evaluate fibular incisura morphologies and fibular orientation. It also defines the frequency of DTFS measures and the interobserver performance on 2 CT evaluation methods.
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http://dx.doi.org/10.1053/j.jfas.2018.05.013DOI Listing
February 2019

Gender Differences on SF-36 Patient-Reported Outcomes of Diabetic Foot Disease.

Int J Low Extrem Wounds 2018 Jun 21;17(2):87-93. Epub 2018 Jun 21.

1 University of Texas Southwestern Medical Center, Dallas, TX, USA.

The primary aim of this study was to evaluate the impact of gender on health-related quality of life (HRQOL) using a generic (Short Form-36 [SF-36]) and region-specific (Foot and Ankle Ability Measure [FAAM]) health measurement tool among a matched cohort of male and female patients with diabetes-related foot complications. The HRQOL of 240 patients with diabetic foot disease was measured using the SF-36 and the FAAM surveys. A total of 120 male patients were matched with 120 female patients with the same primary diagnosis, age, type, and duration of diabetes and insulin use. The SF-36 physical component summary (PCS) and mental component summary (MCS) scores were calculated using orthogonal and oblique rotation methods. The median age of the respondents was 54 years (interquartile range = 46-61). No differences in patient characteristics were found between genders. Among the SF-36 subscales, women reported significantly worse physical function ( P = .014) and bodily pain ( P = .021) scores with a trending decrease in general health score ( P = .067). Subsequently, women had worse orthogonal ( P = .009) and oblique PCS scores ( P = .036) than men. However, orthogonal ( P = .427) or oblique ( P = .140) MCS scores did not differ between groups. No significant differences in FAAM scores with respect to gender were appreciated. Our findings suggest that in patients with diabetic foot disease, women tend to report lower physical HRQOL compared with men. In efforts to increase compliance, providers should recognize the impact of gender on patients' perceptions of foot-related complications of diabetes. This knowledge may improve outcomes by adapting more individualized and gender-specific approaches to patients.
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http://dx.doi.org/10.1177/1534734618774664DOI Listing
June 2018

Scoring Mental Health Quality of Life With the SF-36 in Patients With and Without Diabetes Foot Complications.

Int J Low Extrem Wounds 2018 Mar 16;17(1):30-35. Epub 2018 Mar 16.

1 University of Texas Southwestern Medical Center, Dallas, TX, USA.

The aim of this study was to examine if using orthogonal and oblique factor analysis detect changes in health-related quality of life differently in diabetic patients on the Short Form-36 (SF-36) survey. A total of 155 patients had diabetic foot complications (DFC), and 145 patients had no DFCs. The SF-36 Physical Component Summary (PCS) and Mental Component Summary (MCS) scores were calculated using scoring coefficients determined by orthogonal and oblique rotation principle component analyses of the subscales. The DFC group had lower orthogonal ( P < .00001) and oblique PCS scores ( P < .00001). However, despite lower Mental Health subscale scores in the patients with DFCs, orthogonal MCS scores ( P = .156) did not differ. In contrast, the oblique MCS scores reflected the difference in the Mental Health subscale ( P = .0005). Orthogonal and oblique PCS scores did not differ significantly. However, orthogonal MCS scores were significantly higher than oblique MCS scores in those with DFCs ( P = .0004) and without DFCs ( P = .005). The shorter, 12-item SF-12 survey demonstrated similar results. Poorer physical function leads to higher orthogonal MCS scores than if determined by oblique scoring coefficients since Physical Function, Bodily Pain, and General Health are weighted more negatively in orthogonal coefficients when calculating the MCS score. Oblique scoring coefficients may address this issue, but further study is necessary to confirm whether oblique MCS scores accurately represent the mental health of patients with diabetic foot disease.
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http://dx.doi.org/10.1177/1534734618762226DOI Listing
March 2018

A Biomechanical Analysis of Interference Screw Versus Bone Tunnel Fixation of Flexor Hallucis Longus Tendon Transfers to the Calcaneus.

J Foot Ankle Surg 2017 Jul - Aug;56(4):813-816

Assistant Professor, Division of Mineral Metabolism, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX.

The flexor hallucis longus tendon transfer is commonly used to restore function in chronic Achilles tendon ruptures and chronic Achilles tendinopathy. The tendon is often secured to the calcaneus either through a bone tunnel or by an interference screw. We hypothesized that tenodesis using the bone tunnel method would be mechanically superior to interference screw fixation for flexor hallucis longus transfers. Eight matched pairs of cadaveric specimens were assigned randomly to the bone tunnel or interference screw technique and were loaded to failure. Biomechanical analysis was performed to evaluate the ultimate strength, peak stress, Young's modulus, failure strain, and strain energy. Unpaired comparison, paired comparison, and linear regression analyses were used to determine statistical significance. A slight 22% ± 9% decrease in Young's modulus and a 52% ± 18% increase of strain energy were found in the interference screw group. However, no differences in ultimate strength, peak stress, or failure strain were seen between the 2 groups on paired comparison. Our findings suggest that interference screw fixation provides similar spontaneous biomechanical properties to the use of a bone tunnel for flexor hallucis longus transfer to the calcaneus. The interference screw is a practical option for fixation of the flexor hallucis longus tendon to the calcaneus and can be performed through a single incision approach.
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http://dx.doi.org/10.1053/j.jfas.2017.04.014DOI Listing
March 2018

Simulated radiographic bone and joint modeling from 3D ankle MRI: feasibility and comparison with radiographs and 2D MRI.

Skeletal Radiol 2017 May 6;46(5):651-664. Epub 2017 Mar 6.

Musculoskeletal Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA.

Purpose: The purpose of this work is to simulate radiographs from isotropic 3D MRI data, compare relationship of angle and joint space measurements on simulated radiographs with corresponding 2D MRIs and real radiographs (XR), and compare measurement times among the three modalities.

Materials And Methods: Twenty-four consecutive ankles were included, eight males and 16 females, with a mean age of 46 years. Segmented joint models simulating radiographs were created from 3D MRI data sets. Three readers independently performed blinded angle and joint space measurements on the models, corresponding 2D MRIs, and XRs at two time points. Linear mixed models and the intraclass correlation coefficient (ICC) was ascertained, with p values less than 0.05 considered significant.

Results: Simulated radiograph models were successfully created in all cases. Good agreement (ICC > 0.65) was noted among all readers across all modalities and among most measurements. Absolute measurement values differed between modalities. Measurement time was significantly greater (p < 0.05) on 2D versus simulated radiographs for most measurements and on XR versus simulated radiographs (p < 0.05) for nearly half the measurements.

Conclusions: Simulated radiographs can be successfully generated from 3D MRI data; however, measurements differ. Good inter-reader and moderate-to-good intra-reader reliability was observed and measurements obtained on simulated radiograph models took significantly less time compared to measurements with 2D and generally less time than XR.
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http://dx.doi.org/10.1007/s00256-017-2596-7DOI Listing
May 2017

Risk Factors for Open Malleolar Fractures: An Analysis of the National Trauma Data Bank (2007 to 2011).

J Foot Ankle Surg 2016 Jan-Feb;55(1):94-8. Epub 2015 Sep 26.

Assistant Professor, Department of Preventive Medicine and Community Health, The University of Texas Medical Branch, Galveston, Texas.

A limited number of studies have described the epidemiology of open fractures, and the epidemiology of open ankle fractures is not an exception. Therefore, the risk factors associated with open ankle fractures have not been extensively evaluated. The frequencies and proportions of open ankle fractures among all the recorded malleolar fractures in the US National Trauma Data Bank data set from January 2007 to December 2011 were analyzed. Clinically relevant variables captured in the data set were also used to evaluate the risk factors associated with open ankle fractures, adjusting for other covariates. The entire cohort was further subdivided into "lower" and "higher" energy trauma groups and the same analysis performed for each group separately. We found that a body mass index of >40 kg/m(2) and farm location were risk factors for open ankle fractures and impaired sensorium was protective against open ankle fractures. In the "lower energy" group, male gender, alcohol use, peripheral vascular disease, other injuries, and injury occurring at a farm location were risk factors for open fractures. In the "higher energy" group, female gender, work-related injury, and injury at a farm or industry location demonstrated statistically significantly associations with open fractures.
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http://dx.doi.org/10.1053/j.jfas.2015.07.016DOI Listing
October 2016

Pain Management for Elective Foot and Ankle Surgery: A Systematic Review of Randomized Controlled Trials.

J Foot Ankle Surg 2015 Jul-Aug;54(4):625-35. Epub 2014 Jun 18.

Professor, Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX. Electronic address:

Pain after foot and ankle surgery can significantly affect the postoperative outcomes. We performed a systematic review of randomized controlled trials assessing postoperative pain after foot and ankle surgery, because the surgery will lead to moderate-to-severe postoperative pain, but the optimal pain therapy has been controversial. A systematic review of randomized controlled trials in English reporting on pain after foot and ankle surgery in adults published from January 1946 to February 2013 was performed. The primary outcome measure was the postoperative pain scores. The secondary outcome measures included supplemental analgesic requirements and other recovery outcomes. With 953 studies identified, 45 met the inclusion criteria. The approaches improving pain relief (reduced pain scores or opioid requirements) included peripheral nerve blocks, wound infiltration, intravenous dexamethasone, acetaminophen, nonsteroidal anti-inflammatory drugs, cyclooxygenase-2 selective inhibitors, and opioids. Wound instillation, intra-articular injection, and intravenous regional analgesia had variable analgesia. The lack of homogeneous study design precluded quantitative analyses. Optimal pain management strategies included locoregional analgesic techniques plus acetaminophen and nonsteroidal anti-inflammatory drugs or cyclooxygenase-2 selective inhibitors, with opioids used for "rescue," and 1 intraoperative dose of parenteral dexamethasone. Popliteal sciatic nerve blocks would be appropriate when expecting severe postoperative pain (extensive surgical procedure), and ankle blocks and surgical incision infiltration would be appropriate when expecting moderate postoperative pain (less extensive and minimally invasive surgical procedures). Additional studies are needed to assess multimodal analgesia techniques.
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http://dx.doi.org/10.1053/j.jfas.2014.05.003DOI Listing
March 2016

The economics of limb salvage in diabetes.

Plast Reconstr Surg 2011 Jan;127 Suppl 1:289S-295S

Fort Collins, Colo.; and Dallas, Texas From the Orthopaedic Center of the Rockies and the Departments of Orthopaedic Surgery and Plastic Surgery, University of Texas Southwestern Medical Center and Parkland Hospital.

Background: Limb salvage requires early prevention therapy, knowledgeable use of wound care technology, and active management of peripheral vascular disease. This field has changed considerably over the past decade, with new advanced wound healing products and minimally invasive surgery for peripheral vascular disease. Treatment can be very costly in terms of medical and human resources. Evaluation of the clinical and economic impact of medical care is becoming more important as the population with diabetes and the need to contain the cost of health care simultaneously increase. The aim of this study was to review the economic impact of prevention therapies, wound care, and peripheral vascular disease interventions to prevent major lower extremity amputations.

Methods: The authors reviewed the economic impact of prevention therapy, wound care, and peripheral vascular disease interventions to prevent lower extremity amputations.

Results: Length of stay in the hospital and intensive care drive the cost of treatment. Surgical intervention and complications for foot ulcers, amputations, and peripheral vascular disease are significant factors in the cost of limb salvage.

Conclusions: Not surprisingly, prevention and evidenced-based treatments are the most cost-effective way of reducing the use of medical resources and improving and prolonging productive lifestyles. Future prospective studies need to be conducted to more accurately understand the financial impact of limb salvage.
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http://dx.doi.org/10.1097/PRS.0b013e3181fbe2a6DOI Listing
January 2011

Osteotome axial twist (OAT) technique: a simple method for exposing arthritic foot joints in preparation for arthrodesis.

Authors:
George T Liu

J Foot Ankle Surg 2008 Sep-Oct;47(5):494-6

University of Texas Health Science Center San Antonio, Department of Orthopaedics, San Antonio, TX, USA.

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http://dx.doi.org/10.1053/j.jfas.2008.06.006DOI Listing
November 2008

Digital syndactylization for the treatment of interdigital squamous cell carcinoma in situ (Bowen disease).

J Foot Ankle Surg 2004 Nov-Dec;43(6):419-22

Division of Podiatry, Department of Orthopaedics, University of Texas Health Science Center San Antonio, San Antonio, TX, USA.

Bowen disease, or squamous cell carcinoma in situ, has been described as a premalignant intraepidermal lesion of the skin. Although more frequently occurring on limbs, interdigital presentation of squamous cell carcinoma in situ in the foot has been rarely reported, likely because of undetected development. Excision has been recommended as the treatment of choice; however, removal of these lesions from intertriginous skin may present few options for skin closure. Interdigital syndactylization may be an acceptable option for the treatment of interdigital manifestations of Bowen disease. The authors present a case of interdigital squamous cell carcinoma in situ successfully treated with excision and digital syndactylization. At the 2-year follow-up, there was no recurrence and no digital deformities.
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http://dx.doi.org/10.1053/j.jfas.2004.09.008DOI Listing
April 2005