Publications by authors named "Sara Mateen"

11 Publications

  • Page 1 of 1

A Critical Biomechanical Evaluation of Foot and Ankle Soft Tissue Repair.

Clin Podiatr Med Surg 2022 Jul;39(3):521-533

Department of Podiatric Surgery, Temple University School of Podiatric Medicine, Philadelphia, PA, USA. Electronic address:

The objective of this article is to review the biomechanical stresses that occur during normal physiologic function of lower extremity soft tissue anatomic structures and to use this as a baseline for a critical analysis of the medical literature because it relates to surgical reconstruction following injury. The Achilles tendon, anterior talofibular ligament, plantar plate, and spring ligament are specifically evaluated.
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http://dx.doi.org/10.1016/j.cpm.2022.02.011DOI Listing
July 2022

Surgical Anatomy of the Endoscopic Gastrocnemius Recession.

J Foot Ankle Surg 2022 Jul-Aug;61(4):686-688. Epub 2021 Nov 7.

Clinical Professor, Department of Podiatric Surgery, Temple University School of Podiatric Medicine, Philadelphia, PA. Electronic address:

The objective of this investigation was to analyze the surgical anatomy of the endoscopic gastrocnemius recession procedure with reference to the curved nature of the aponeurosis. A consecutive series of 34 magnetic resonance imaging scans were evaluated under the direction of a musculoskeletal radiologist. An angular calculation of the effective curvature of the aponeurosis was measured 2 cm distal to the musculotendinous junction based on the maximal posterior excursion and terminal medial and lateral edges. A frequency count was additionally performed of the number of deep intramuscular septa extending from the aponeurosis, as well as a description of the location of the neurovascular bundle in this location. The mean effective curvature was 126.5 degrees (standard deviation [SD] = 6.3 degrees, range 115-143 degrees, 95% confidence interval 124.3-128.7 degrees). We observed an average of 1.2 (SD = 0.5, range = 0-2) deep intramuscular septa extending from the aponeurosis, and that 20.6% of neurovascular bundles were located superficial to the aponeurosis in this location. In conclusion, we found that a straight cannula needs to be navigated around an approximate 125-degree angle during performance of the EGR procedure. We think that this information provides evidence of potentially unrecognized complications of this procedure and leads to future investigations demonstrating anatomic and procedural outcomes.
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http://dx.doi.org/10.1053/j.jfas.2021.10.030DOI Listing
June 2022

Normal Distal Excursion of the Peroneus Brevis Myotendinous Junction.

J Foot Ankle Surg 2021 Oct 22. Epub 2021 Oct 22.

Clinical Professor, Department of Podiatric Surgery, Temple University School of Podiatric Medicine, Philadelphia, PA. Electronic address:

A low-lying peroneus brevis muscle belly has been described as a risk factor for the development of peroneal tendon pathology, but this finding has primarily been described based on cohorts with pre-existing clinical findings. Therefore, the objective of this investigation was to evaluate the frequency of apparently abnormal low-lying muscle bellies from a series of subjects without clinical or imaging findings of peroneal tendon pathology. One hundred consecutive MRIs were reviewed with measurement of the distance from the distal peroneal myotendinous junction to the tip of the fibula. This distance was observed to be 23.9 ± 8.8 mm (10.8-55.4 mm; 95% confidence interval 22.2-26.7 mm). If one assumed that a myotendinous junction within 2 cm of the distal tip of fibula represented an abnormal low-lying muscle, then we observed 37% of extremities without clinical or radiographic evidence of peroneal tendon pathology that would be considered anatomically "abnormal." When a low-lying muscle belly was defined as occurring within 2 cm of the distal tip of the fibula, then a probability analysis of our data distribution found a 32.6% probability for individuals to have an "abnormally" low-lying muscle belly. These results indicate that what has traditionally been defined intraoperatively as an abnormally low-lying peroneus brevis muscle belly might simply represent intraoperative confirmation bias of relatively normal structural anatomy.
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http://dx.doi.org/10.1053/j.jfas.2021.10.013DOI Listing
October 2021

Diagnosis, imaging, and potential morbidities of the hallux interphalangeal joint os interphalangeus.

Skeletal Radiol 2022 Jun 26;51(6):1143-1151. Epub 2021 Oct 26.

Department of Radiology, Temple University Hospital, Philadelphia, PA, USA.

Hallux pain is a common entity with a differential diagnoses including hallux valgus, hallux limitus/rigidus, and gout and specifically at the interphalangeal joint (IPJ), flexor hallucis longus (FHL) tenosynovitis, and joint arthrosis. An under-recognized source of pain is the os interphalangeus, an ossicle typically located at the plantar aspect of the hallucal interphalangeal joint. This ossicle is radiographically visible in its ossified form in 2-13% of individuals, but can also be present as an ossified or non-ossified nodule in patients. The os interphalangeus may be centrally or eccentrically located, and although originally believed to be a sesamoid bone in the FHL tendon, it is an ossicle located in the joint capsule of the IPJ and separated from the tendon by a bursa. When the ossicle is absent, the bursa is also absent and the tendon is attached to the joint capsule. Infrequently, the os may be located eccentrically under the first IPJ and reflect persistence of one of the distal phalanx. Rarely, the os interphalangeus may be dorsal to the IPJ. The os interphalangeus is best evaluated on radiographs, ultrasound, and MRI. Pain is a result of altered mechanics with arthrosis or frictional effects with bursitis, tenosynovitis, or intractable plantar keratosis (IPK). The ossicle may also displace into a dislocated IPJ, preventing reduction. The os interphalangeus may be centrally or eccentrically located, and although originally believed to be a sesamoid bone. This has been found within the plantar joint capsule of the distal hallucal interphalangeal joint and separated from the tendon by a bursa. Uncommonly, the location may be plantar eccentric and reflect persistence of one of the ossification centers of the distal phalanx. Although the ossicle can be imaged with standard AP and lateral radiographs in many cases, in those cases of unexplained pain with no radiographically visible ossicle, and the presence of friction blisters, intractable plantar keratosis (IPK), hyper-extension of the IPJ, hallux limitus/rigidus, or metatarsophalangeal joint (MTPJ) arthrodesis, an MRI or CT should be considered to identify a non-ossified fibrocartilaginous node. This is of particular concern in a patient with a history of underling diabetes mellitus or other metabolic disorders associated with diminished pedal sensation where neurotrophic changes place them most at risk for complications associated with excessive plantar pressure. Pain is a result of altered biomechanics with arthrosis, or frictional effects causing bursitis, tenosynovitis, or IPK. The ossicle may also displace into a dislocated IPJ, preventing reduction. In this article, we will describe the anatomy and imaging appearance of the common os interphalangeus variants and associated complications including frictional effects, arthrosis, and IPK and discuss conservative and surgical management of a symptomatic ossicle.
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http://dx.doi.org/10.1007/s00256-021-03946-xDOI Listing
June 2022

Responsiveness and Inter-Rater Reliability of the Pulse Volume Recording Upstroke Ratio (PVRr).

J Foot Ankle Surg 2022 May-Jun;61(3):486-489. Epub 2021 Sep 25.

Clinical Professor, Department of Podiatric Surgery, Temple University School of Podiatric Medicine, Philadelphia, PA. Electronic address:

The objective of this study was to evaluate a measure of the responsiveness and reliability of the pulse volume recording upstroke ratio (PVRr). A database of 389 subjects undergoing lower extremity revascularization was analyzed. Subjects were included in the analysis if they had undergone pedal radiographs, had PVRs performed pre- and postlower extremity revascularization, and had regular pulsatile digital waveforms with a pressure recording on both PVRs. The responsiveness of the PVRr was assessed by means of the postoperative percent change in comparison to the digital pressures. A statistically significant negative correlation was observed (Pearson -0.421; p = .007) indicating that as digital pressures increased, the PVRr decreased. Further, measurement of the reliability of the PVRr was performed on a selection of 10 recordings by 2 residents and 3 board-certified surgeons. The observed intraclass correlation coefficient of measurements was 0.960. Results of this investigation provide evidence in support of the responsiveness and inter-rater reliability in the calculation of the pulse volume recording upstroke ratio.
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http://dx.doi.org/10.1053/j.jfas.2021.09.023DOI Listing
May 2022

Approximation of the Ankle-Brachial Index in the Setting of Medial Arterial Calcific Sclerosis.

J Foot Ankle Surg 2022 Mar-Apr;61(2):314-317. Epub 2021 Sep 9.

Clinical Professor and Chair, Department of Vascular Surgery, Temple University Hospital, Philadelphia, PA.

The presence of medial arterial calcific sclerosis is known to cause inaccuracy in the interpretation of noninvasive vascular testing. This substantially limits the utility of an important baseline diagnostic test for peripheral arterial disease. Therefore, the objective of this investigation was to derive a method to effectively factor out calcification in the interpretation of the ankle and digital brachial indices. The noninvasive vascular testing results of 160 subjects were stratified into the absence of calcification, mild calcification, moderate calcification, and severe calcification based on plain film radiographic findings of the infrageniculate vessels. Measurements were then performed of the pulse volume recording (PVR) waveforms at brachial, ankle and digital anatomic levels to include PVR wavelength and PVR upstroke length, with a calculation of the ratio of PVR upstroke length to PVR wavelength. These measurements were compared between groups and then correlated to the ankle and digital brachial indices. A significant difference was observed in the PVR upstroke ratio between the 3 anatomic levels (0.1818 vs 0.2622 vs 0.3191; p < .001), but not between the 4 calcification groups (0.2457 vs 0.2363 vs 0.2694 vs 0.2631; p = .242). A significant negative correlation was observed between the PVR upstroke ratio and the ankle brachial index (ABI) (Pearson -0.454; p = .002) with linear regression indicating the relationship is defined by the formula: Effective ankle brachial index = 1.17 - (1.33 × PVR upstroke ratio at ankle level). A significant negative correlation was also observed between the PVR upstroke ratio and the digital brachial index (Pearson -0.553; p < .001) with linear regression indicating the relationship is defined by the formula: Effective toe brachial index = 1.04 - (1.61 × PVR upstroke ratio at digital level). The results of this investigation demonstrate the feasibility of, and provide equations to approximate, the effective ankle brachial and toe brachial indices in the setting of medial arterial calcification.
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http://dx.doi.org/10.1053/j.jfas.2021.09.001DOI Listing
March 2022

A Comparison of Adverse Short-Term Outcomes Following Forefoot Amputation Performed on an Inpatient Versus Outpatient Basis.

J Foot Ankle Surg 2022 Jan-Feb;61(1):67-71. Epub 2021 Jun 20.

Clinical Assistant Professor, Department of Podiatric Surgery, Temple University School of Podiatric Medicine, Philadelphia, PA.

The objective of this investigation was to evaluate short-term adverse outcomes following forefoot amputation with a specific comparison between those procedures performed on an inpatient versus outpatient basis. The 2018 American College of Surgeons National Surgical Quality Improvement Program database was interrogated to select those subjects with a 28805 current procedural terminology code (amputation, foot; transmetatarsal) that underwent the procedure with "all layers of incision (deep and superficial) fully closed." This resulted in 326 subjects who underwent the procedure on an inpatient basis and 72 subjects who underwent the procedure on an outpatient basis. Results of the primary outcome measures found no significant differences between groups with respect to the development of a superficial surgical site infection (5.8% vs 5.6%; p = .950), deep incisional infection (3.4% vs 5.6%; p = .380), or wound disruption (3.4% vs 6.9%; p = .163). Additionally, no significant differences were observed between groups with respect to unplanned reoperations (15.6% vs 12.5%; p = .500) or unplanned hospital readmissions (21.8% vs 23.6%; p = .957). The results of this investigation demonstrate no difference in short-term adverse outcomes following the performance of forefoot amputation with primary closure when the procedure is performed on an inpatient or outpatient basis. We hope that this information is utilized in future investigations specifically examining this clinical scenario as it relates to hospital admission criteria related to lower extremity tissue loss, length of hospital stay considerations, the timing of partial foot amputation following revascularization, and the economics of limb preservation.
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http://dx.doi.org/10.1053/j.jfas.2020.07.007DOI Listing
January 2022

Evaluation of the Relationship Between Aspects of Medical Complexity and Work Relative Value Units (wRVUs) for Foot and Ankle Surgical Procedures.

J Foot Ankle Surg 2021 May-Jun;60(3):448-454. Epub 2020 Jul 3.

Clinical Associate Professor, Department of Podiatric Surgery, Temple University School of Podiatric Medicine, Philadelphia, Pennsylvania.

Work relative value units (wRVUs) have been assigned to current procedural terminology codes in an effort to help establish physician compensation. However, the ability of these to accurately and efficiently capture the time, technical, and perioperative managerial aspects required of various procedures has recently been called into question for several surgical subspecialties. Therefore, the objective of this investigation was to evaluate various measures of medical complexity against wRVUs for foot and ankle surgical procedures. The 2018 American College of Surgeons National Surgical Quality Improvement Program database was utilized to identify and extract data related to the perioperative medical complexity of 16 foot and ankle surgical current procedural terminology codes. We observed a "weak" positive relationship between wRVUs and operation time as defined by a correlation coefficient of 0.234 (p < .001). Other variables associated with medical complexity in the perioperative period were found to significantly vary between wRVUs categories, but these differences were neither consistently nor directly associated with assigned relative values. We conclude that wRVUs might not always represent an efficient means for determining compensation for foot and ankle surgical procedures.
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http://dx.doi.org/10.1053/j.jfas.2020.06.022DOI Listing
June 2021

Retrospective chart review of perioperative pain management of patients having surgery for closed ankle fractures using peripheral nerve blocks at a level one trauma center.

Pain Rep 2021 Jan-Feb;6(1):e900. Epub 2021 Feb 16.

Department of Anesthesiology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA.

Chronic opioid use is unfortunately perceived among these postoperative patients, specifically within orthopedic surgery. Patients having orthopedic surgeries are at risk for becoming addicted to opioids, and one benefit of peripheral nerves blocks could be to provide an alternative mode of pain control. This study takes a retrospective look at the use of peripheral nerve blocks for pain control following surgery for isolated traumatic ankle injuries. We hypothesize that when peripheral nerve blocks are administered preoperatively to patients with closed ankle fractures, they will have overall better control of postoperative pain compared to patients who did not receive a peripheral nerve block.

Objectives: The objective of this investigation was to evaluate the effect of preoperative peripheral nerve blockade on pain outcomes after ankle fracture surgery.

Methods: After approval from our institutional review board, a Current Procedural Terminology code search was performed of all patients within our institution over a 3-year data collection period (August 2016-June 2019). This resulted in 177 subjects who underwent isolated closed ankle fracture open reduction internal fixation (ORIF), of which 71 subjects met inclusion criteria.

Results: Results of the primary outcome measures found no difference in the mean postoperative care unit (PACU) pain scores between the groups (2.39 ± 2.91 vs 3.52 ± 3.09; P = 0.1724) nor the frequency of those who reported only mild pain (63.0% vs 47.10%; P = 0.2704). Subjects who received a peripheral nerve block spent more time in the PACU before discharge (2.06 ± 1.05 vs 0.94 ± 1.21 hours; P = 0.0004). Subjects receiving a peripheral nerve block were more likely to be given no analgesics in the PACU (38.9% vs 11.8%; P = 0.042) and less likely to receive a narcotic analgesic in the PACU (53.7% vs 82.4%; P = 0.047).

Conclusion: Although the results of this investigation demonstrate no significant difference in the mean PACU pain scores, they do demonstrate a significant difference in the amount of pain medication given in the PACU setting. This information will be used for future investigations of this discrepancy between pain perception and need for immediate postoperative pain medications as it relates to multimodal pain control in the setting of ankle fracture surgery.
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http://dx.doi.org/10.1097/PR9.0000000000000900DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7889403PMC
February 2021

Thyroid Dermopathy Treatment of the Foot in the Setting of Graves Hyperthyroidism.

J Foot Ankle Surg 2021 Jul-Aug;60(4):834-838. Epub 2021 Jan 26.

Clinical Professor, Department of Surgery, Temple University School of Podiatric Medicine, Philadelphia, PA.

Graves' hyperthyroidism is one of the most common autoimmune diseases, caused by autoantibodies acting against the thyrotropin receptor. Extra-thyroid manifestations include ophthalmopathy, acropachy, and dermopathy, which accounts for 4% to 13% of clinical presentations. This is a case study of a 55-year-old female who presented with recurrent soft tissue mass formation over the dorsal right foot. The patient underwent a soft tissue mass excisional biopsy and the pathology report revealed a soft tissue mass secondary to thyroid dermopathy. Given her history of soft tissue recurrence and previous diagnosis, the patient underwent both excisional biopsy and radiation treatment with success. After 1 year of follow-up, the patient had completely healed without complication. This case demonstrates a multidisciplinary approach for clinical diagnosis and treatment.
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http://dx.doi.org/10.1053/j.jfas.2020.12.002DOI Listing
July 2021

Lower Extremity Non-Blanchable Purpura Secondary to Methotrexate Toxicity: A Case Report.

J Foot Ankle Surg 2020 Nov - Dec;59(6):1272-1274. Epub 2020 Jul 28.

Clinical Professor, Department of Surgery, Temple University School of Podiatric Medicine, Philadelphia, Pennsylvania.

Methotrexate is an antimetabolite drug that works as a folic acid analogue to inhibit DNA synthesis. This drug is commonly used for treating conditions such as psoriasis, rheumatoid arthritis, atopic dermatitis, and collagen disease. Although methotrexate may have common adverse effects such as bone marrow suppression and liver abnormalities, less commonly encountered side effects include lower extremity cutaneous blistering and skin necrosis. To our knowledge, there have been no case reports that have described methotrexate toxicity to the foot and ankle. This case report highlights a case of a 61-year-old patient who initially presented to our hospital with a 2-day history of worsening pain, swelling, and blistering of his feet. The patient's initial diagnosis was secondary to burns; however, with thorough investigation, imaging, and a punch biopsy, the final diagnosis was secondary to methotrexate toxicity. This case emphasizes the importance of a thorough history and physical examination for proper diagnosis and treatment of the adverse effect of methotrexate toxicity.
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http://dx.doi.org/10.1053/j.jfas.2020.03.022DOI Listing
June 2021
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