Ankle Surgery Update

The FuSpruLMU Hot Wire #1

November 07, 2020 Ankle Surgery Update / Prof. Dr. Cesar de Cesar Netto / Prof. Dr. Alexej Barg Season 1 Episode 10
Ankle Surgery Update
The FuSpruLMU Hot Wire #1
Show Notes Transcript

Hey everybody!

Welcome to this month’s special of the Ankle Surgery Update – Science guiding treatment! Science is teamwork. In our new special “The FuSpruLMU Hot Wire” we present papers from our group which are commented by independent experts in the field. As always, you can find this podcast on all common platforms and feel free to join us a #FuSpruLMU. The papers for this first special issue are:

  • Rellensmann, K., Behzadi, C., Usseglio, J., Vosseller, J., Böcker, W., Polzer, H., Baumbach, S. (2020). Acute, isolated and unstable syndesmotic injuries are frequently associated with intra-articular pathologies Knee Surgery, Sports Traumatology, Arthroscopy ( commented by Prof. Dr. Cesar de Cesar Netto (@Dr_deCesarNetto) and 
  • Hörterer, H., Baumbach, S., Oppelt, S., Böcker, W., Harrasser, N., Walther, M., Polzer, H. (2020). Complications Associated With Midline Incision for Insertional Achilles Tendinopathy Foot & Ankle International ( commented by Prof. Dr. Alexej Barg

Enjoy listening!

Ankle Surgery Update  0:12 
Welcome to this episode of ankle surgery update signs guiding treatment. We have received great feedback through our social media channels, especially LinkedIn, we do have the feeling that most of you appreciate the scientific approach of our podcast, which we are very grateful for. We strongly believe that the unique selling point of ankle surgery update is the critical summary of the hot papers presented each month. Still, we would like to implement new presentation formats to keep this podcast interesting. You all know that research is only possible as a team effort. We not only rely on our residents, but also collaboration partners and friends to conduct high quality studies next door daily clinical business. Therefore, we decided to give our residents collaborators and friends a platform to present our co authored works. Obviously hands on me are biased and therefore we are not the perfect fit to discuss these papers. Consequently, in our new section, the FuSpruLMU Hot ire we will have key opinion leaders give commentaries in these sections. The first paper presented in the FuSpruLMU Hot Wire is entitled, acute, isolated and unstable syndesmotic injuries are frequently associated with intra articular pathologies published in K as sta July 2020. The paper will be presented to you by Katherine groundsmen, who's one of our residents. Katherine, thank you very much, and we're very much excited to hear about your study.

Kathrin Rellensmann  1:44 
In the following few minutes, I will give you a brief overview on what we did in our study. It does fit pretty good into an early episode of this podcast, as it also addresses potential benefits of additional arthroscopy and ankle injuries. As discussed recently, arthroscopic assist the treatment of complex ankle fractures is common. The rationale behind the additional trust copy is the diagnosis of intra articular pathologies, such as also control and control lesions or loose bodies, although this might also be achieved by preoperative MRI. Despite its lower sensitivity, trust copy has the advantage of instant treatment of these pathologies, high ankle sprains acute predominantly in high impact sports, and the actual trauma mechanism and force is pretty similar to ankle fractures. Therefore, we hypothesized that acute isolated unstable syndesmotic injuries may present with a similar rate of intra articular pathologies as ankle fractures. Based on these considerations, we started additional atrocity in patients suffering and acute unstable syndesmotic injury in mid 2014. At the food and ankle division of the University Hospital in unique Allen, we now wanted to evaluate the frequency of intra articular pathologies in these patients. Based on a retrospective chart review, we identified all patients above the age of 17, who underwent an arthroscopic assisted civilization for an acute syndesmotic instability, acute was considered within the first 12 weeks isolated was defined as a ligamentous injury and or avulsion fractures of this in this multi complex instability was identified by the external rotation test under fluoroscopy. Next to demographics, injury pattern, treatment and complications we assess the frequency of intra articular pathologies and rated the location and severity of cartilage lesions according to the icrs grading system. Furthermore, a blinded radiologists specialized in Mfk reviewed the initial MRI images for any intra articular pathology using the same grading system that was applied for the arthroscopic findings. 27 patients were included in the final analysis. Starting with the actress Copic findings, contra lesions were present in 48% of patients 15% of which were icrs grade four and were treated by micro fracturing. Furthermore, 11% of patients presented with the loose body which was also removed during arthroscopy. Interestingly, there was no influence of the type of syndesmotic injury ligamentous versus of origin or the degree of instability on the occurrence of intra articular pathologies. complications are cured in one patient which needed one of the arthroscopy portals revised the blinded MRI review revealed control lesions icrs grade four and all loose bodies in 35% of the patients We then compare these to the arthroscopic findings. MRI had a sensitivity specificity for congra lesions of 100% 79% and for loose bodies of 50% 93%, respectively, additional arthroscopy Barris a general complication rate of about 5% compared to a neglectful complication rate for MRI. If additional arthroscopy for unstable syndesmotic injuries is recommended, its benefit must outweigh its complication. Based on our findings, pre operative MRI did detect all icrs grade four conroe lesions, but did miss half of the intraarticular bodies. Hans Sebastian and me thoroughly discussed these findings and their implication on our treatment algorithm for acute unstable isolated syndesmotic injuries. We now only recommend additional arthroscopy, independent of the MRI for any patient with high physical demands. In older patients with moderate level of activity, we stick to the MRI findings and adapt our treatment accordingly.

Ankle Surgery Update  6:09 
Professor Dr. seiza, DC said netta sees as received as medical education initial training at the University of South Paulo Brazil, followed by several clinical fellowships at the University of Alabama Birmingham, the hospital for special surgeries at the medstar Union Memorial Hospital. He now works as an assistant professor at the University of Iowa.

Prof. Dr. Cesar de Cesar Netto  6:32 
My name is Cesar Cesar natto. I'm an assistant professor at University of Iowa Department of Orthopedic rehabilitation, I will see the United States. I'm going to provide some comments on a recent publication at the knee surgery sports dermatology arthroscopy giorno publication entitled acute isolated and stables and demonic injuries are frequently associated with in particular pathologies by first outer get through railings men and last outer Sebastian fabrics bound back. The main focus and rationale of the outdoors for this publication was looking to patient with isolated unstable syndesmotic injuries, undergoing surgical treatment to check the influence of arthroscopy in assessing the presence of in particular associated pathologies that could potentially happen. Together with the center's modic isolated injuries. They hypothesized that the presence of intra articular lesions would be common in patients suffering of acute isolated and stables in this model dangerous period. The rationale for that would be that there's not enough information in the literature regarding the prevalence of intramuscular injuries in patients with the isolated unstable syndesmotic dangerous the overall assessment of this research study is good. I believe that the main limitations of the study are related to the retrospective nature of the study and that is acknowledged by the outdoors during the discussion. We all know how difficult it is to go back into chart reviews and identify detailed information especially surgical descriptions of procedures like arthroscopic procedures, relying on the chart review to identify exact descriptions of presence and location of hunger injuries, as well as presence of loose bodies is always a risky move, that I'm sure that the outers took care to be very precise with their definitions and harvesting of the data. Another important factor that is limited by the retrospective nature of the study is related to the proper definition of the unstable and as minor injuries either by clinical examination stradic the nation under fluoroscopic assessment and assessment through MRI studies when the MRI was present, and also inter operatively by stress test under arthroscopic evaluation, even though the outers discuss in reported that they define an unstable injuries, when to ligament instability, were proven by the act Roscoe for your functional radiographic examination, I wonder how that was really performed? And would they be accurate enough to make sure or to identify the two out of three ligaments would be completely ruptured causing instability since that assessment is very controversial in the literature, and other important limitation of the study was the fact that no sample size or no power analysis was performed before the initiation of the study. And some of the findings for example, the fact that they did not find any influence of the level of instability are the type of this is not an injury, either an isolated ligamentous injury or a bony emotion injury, especially when there was a presence of a posterior malleolar fracture could be related to the fact that these simple is undersized and wouldn't have enough power to demonstrate differences between the group. It would make sense in my opinion that the more unstable injuries and coaly the ones with more bony injuries such as devotion would be correlated with more frequent intra articular pathology that do not show to be significant in the results of these retrospective cohort study. However, I do believe that this study adds more information for us in the literature, they demonstrated that almost 50% of the patients with isolated unstable centers, mic injuries did have in particular apologies, either condra lesions or lose bodies, and some of them would necessitate additional treatment for them. The other thing is, they found out that even though MRIs were not present for all the patients, and we discussed before that they acknowledged that the quality of the MRIs were significantly different between each one of the cases, they did find that you have a negative MRI, the likelihood that you would find a particular pathology in the outer scopic assessment would be low, then we'll show you in the high negative predictive value of the MRI, I would congratulate the outdoors for the publication. And for the fact that they were very focused and honest on acknowledging the limitations of their studies, I would recommend them to do a further assessment pretty much with similar concept, but doing this now on a prospective manner, where they would be focusing on gathering very detailed and specific intra operative data, as well as having patience to get MRIs of homogeneous quality preoperatively. So the comparison between arthroscopic in MRI findings would be fair and would happen in a controlled manner. Another recommendation would be to be very precise with the way we would define the isolated injuries and we would define instability even knowing that it's a very controversial subject in the literature, I would recommend being very specific in how we would diagnose the instability arthroscopically such as inserting a 2.5 millimeters fear or too many meters fear into the kinematic integer doing arthroscopic assessment with or without external rotation stress, and or using preoperative external rotations to add with very well defined tibia fibula clearspace widening assessment or even making these more accurate if they had the chance to use weightbearing CT to assess as soon as my area or syndesmotic volume into this equation. Other than that, again, congratulate the authors for the publication, and we're adding some important data to the body injury each insure.

Ankle Surgery Update  13:27 
The next article presented in this new section is entitled complications associated with midline incision for insertion and Achilles tendinopathy, published in f&i in August 2020. The paper will be presented to you by who but heard of her who is not only one of the leading consultants from Professor Marcus welter at the foot and ankle department of the shoe clinic mentioned hollowing, but he's also a close friend and important collaborator to us.

Dr. Hubert Hörterer  13:54 
Thank you very much for the invitation to your podcast, Dr. Hans and Sebastian. I'm very delighted to present our work today on air. My name is Dr. Hubert Hunter. I'm one of the leading Senior Consultant at the Center for foot and ankle surgery at the schoon Clinic mentioned alaafin here in Munich. I'm the first author of our joint paper entitled complications associated with midline incision for insertional Achilles tendinopathy. The correct treatment of it remains a challenge for every foot and ankle surgeon in case of fate non operative treatment, he has an ongoing debate regarding the most beneficial surgical approach to address it. At least since the landmark paper often died in 2011. We know how to classify the numerous pathologies in it, but it actually remains unknown which of these radiologic pathologies does cause symptomatic it is most of them can also be found in asymptomatic patients. Because of this uncertainty open debridement of open ologies through extend side approaches is still regular Delivery performed. Also various studies have reported complication rates between seven and 30%. Studies clearly focusing on complication rates following open debridement are rare. The aim of this study was to assess the complication rate and possible influencing factors following open debridement of all pathologies through a midline incision transit hillarie approach. To do so, we conducted a retrospective study with the follow up of at least one year, inclusion criteria were entered patients presenting with an isolated unilateral it and say non operative treatment. The required minimum follow up was one year, all patients were treated through a midline incision transaxillary approach in all pathologies worthy provided. patient records were analyzed for demographics, duration of symptoms, surgery procedures performed and complications. The surgery procedures were categorized Hertha pathologies debrided. These were according to vandyke dausa bone spurs, intravenous calcifications, Achilles tendon each generations, including partial ruptures, superficial packing yo boo situs ritual of hilarie society's posterosuperior Kenyan prominence is the so called hoglund exostosis and it is reattachment next to the individual pathologies, we calculated the Assam as a surrogate parameter for the surgical invasiveness, complications were categorized into minor and major, the minor complications were defined as complications that did not require additional surgery. Finally, patient satisfaction was rating using a three item Likert scale, in total hundred 18 patients which equals a follow up rate of 63%. With the mean follow up of 4.2 plus minus two years were included in the final analysis. No major complications were observed, but 20 minor complications occurred in 17 patients, which equals 14% of the included patients. similar to previous studies, surgical site infections were the most common complications with 75%. Further, 41% of the patients had problems finding proper shoes, and 32% reported a shoe conflict. Over 60% of these patients noted that those shoe related problems originated from the surgical scar. Overall, 78% of patients were very satisfied with surgery, and almost 90% would recommend the surgery to a close relative. Interestingly, neither the individual surgical procedures not as some had an influence on the complication rate in our cohort. We choose to include the some of the procedures as we believe that a some would function as a surrogate parameter for the invasiveness of the surgery. Still, no negative influence on the company's rate could be detected. the only factor that negatively influences the patient said sections was the shoe conflict. So in conclusion, the hero conducted solo deployment of all pathologies in IIT through a midline incision transaxillary approach resulted in a minor complication rate of 14% 75% of which was surgical site infections. These figures are in line with previous studies. Neither the demographics nor the medical history of surgical invasiveness had a significant influence on the complication rate, but almost one third of the patients complained of residual impairments due to a painful scar. Moreover, this shoe conflict was the only factor to significantly negatively affect patient satisfaction. to us. This study does highlight the limitations of the currently applied midline incision transaxillary approach for IoT and underscores the need for less invasive surgical approaches.

Ankle Surgery Update  19:07 
We now we hear a commentary on this study from Professor Dr. Alexei bar. He has just moved from the United States back to Europe. Alexei has been trained by bt Hyndman victim other abbarno and Charles Saltzman and has now become the head of the foot and ankle department at the University of Hamburg.

Prof. Dr. Alexej Barg  19:26 
Hello, everybody. My name is Alexey Barg. And first of all, I would like to thank Dr. Hubert Hörterer and Dr. Sebastian Baumbach, put a kind invitation to review the paper and titled complications associated with midline incision for insertional Achilles tendinopathy, authored by Dr. Hubert Hörterer at all to introduce myself very briefly since May 2020. I'm working As a hat off with an ankle department into Orthopedic Clinic at the University of Hamburg. Prior to that, I was working for more than six years as Associate Professor for for the ankle surgery. At the University of hue there were still remain as adjunct Associate Professor affiliated. the above mentioned paper has been published just recently in 2020 in with an ankle International, which is actually journal number one for foot and ankle surgery. This is a retrospective cohort study with all consecutive patients who had midline incision surgery for insertional Achilles tendinopathy, performed between January 2010 and October 2016. All surgery have been performed in this single foot and ankle Reference Center, which actually avoids heterogeneity bias of the included patient cohort and the surgical procedure has been described in quite great detail as well as their rehabilitation. In total 118 patients were available for the final analysis, which is actually one of the largest available number in their current future regarding this orthopedic problem. The mean follow up in this study was slightly over a four year and only patients with a minimum follow up of 12 months or included into this study. The outcome parameters were divided into the two major group primary outcome and secondary outcome. And the primary of the include complication rates, including possible scar associated problems. And the secondary outcome parameters do include return to work return to sports, patient satisfaction, and recommendation of surgery to close relative and finally possible shoe conflict insertional Achilles tendinopathy is actually an important part of my daily practice. And also I'm very interested in clinical research of the subject there before I read this paper with great interest and the others are to be commended for the excellent publication as this publication substantially add to important knowledge on this area. This paper actually primarily addressing the rate of complications, which in my opinion, the most important question in every clinical study, no major complications were observed in the percentage cohort of patients. However, a minor complication occurred in 70 patients resulted in a total of 14% of the entire patient group. The author's did actually an excellent job of describing all those complication and explaining how the patient didn't recover following these problems, is another step that offers a deeper form the analysis of factors influencing the positive or negative outcome. For me one of the biggest surprise was that the minor complications did not significantly increase the risk, often shoe conflict, which we all actually observe very often in our practice. As I mentioned before, I enjoy cleaning these paper and I was thouroughly in brass how exactly authors describe all complication in this patient cohort. In my opinion, this paper substantially add important knowledge to the available literature on this field. I personally choose a needle incision for surgical treatment off insertion Achilles tendinopathy my patients, however, there is a still viable debate whether the midline incision may result in scar tissue problems resulting in bigger problem with shoewear. However, dark earth are all we're able to demonstrate that the midline incision surgically insertional Achilles tendinopathy results in a quite moderate minor complication rate without a major complications. They were also able to show quite promising meeting results regarding patient satisfaction including possibly Problems with wearing tight shoes. Having published a few articles myself, I know from my own experience, how difficult it is to write about balanced discussion, and Dr. Hurt are all considered an excellent job to discuss the results in the current application. First of all, they reviewed all important available literature in this topic demonstrating a deep knowledge on this field. Secondly, they were able to explain the possible reasons for the communication observe in the own cohort. And they actually suggested some ways how to avoid those complications. And finally, the author's very honest launching some limitations of the present study is the author's mentioned one of the largest limitation of the presence dining is their introspective nature of publication. However, the maturity of clinical studies on this topic are retrospective. I fully understand that the primary outcome and the primary aim of this study was to describe the complication rate. However, I would like to know how the patients are doing in this study regarding functional outcome and pain relief. Goodness be also of great interest to know how quickly indeed the patient in this cohort recover, because based on my personal experience directly with patients following the surgery on Achilles tendon, it can take a substantial amount of time, at least off months. In summary, I would like again, congratulate all co authors on the great publication on this important topic, and I look forward very much to read more clinical studies. Thank you very much again, for this possibility to share my thoughts. I will you all the best and most importantly, you should stay safe and healthy in these difficult times. Thank you very much.

Ankle Surgery Update  27:26  
We hope you've enjoyed our new section, the FuSpru LMU hot wire. We'd like to thank everyone who's participated in this episode. It was a great pleasure to work with seasoned Alexei and we definitely enjoy this new format. As always, you can find us on almost all platforms and feel free to follow us at Fu spru lm and have a great week and we hope you tune in again to ankle surgery update science guiding

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