Fanter NJ, Inouye SE, McBryde AM. Safety of ankle trans-syndesmotic fixation.  Foot Ankle Int.  2010 May; 31(5): 433-40. (PubMed ID: 20460071)

WHY did the authors undertake this study?
Adding to the complicated issue and peri-operative considerations of trans-syndesmotic screw fixation is the relationship of the screw(s) to surrounding anatomic structures.  Specifically, the authors of this study endeavor to define the structural relationship of the trans-syndesmotic screw to the perforating branch of the peroneal artery (PBPA).

HOW did they attempt to answer this question?
The primary outcome measures of the study are measurements of several distances:  (1) from the PBPA to the threads of the syndesmotic screw, (2) from the PBPA to the tibial plafond, (3) from the PBPA to the distal tip of the lateral malleolus, and (4) from the syndesmotic screw to the distal tip of the lateral malleolus

The study was performed on 16 dissected cadaveric specimens, and a single syndesmotic screw (4.5mm fully threaded cortical) was inserted according to AO technique 2cm proximal and parallel to the tibial plafond.

WHAT were the specific results?
Statistically significant differences were found  between male and female specimens for several of these measurements.  The average distance between the PBPA and the threads of the syndesmotic screw (measurement #1) were 1.3cm for males and 0.85cm for females.  The average distance between the PBPA and the tibial plafond (measurement #2) was 3.97cm for males and 2.92cm for females.    Although none of the syndesmotic screws penetrated the PBPA, the distance was less than 1cm in 38% (6/16) of specimens.

HOW did the authors interpret these results?
From these results, the authors concluded that trans-syndesmotic screw fixation places the PBPA at risk, and they recommend that fixation should be avoided if possible in several zones:  2.3-4.1cm proximal to the tibial plafond for females, and 2.8-5.9cm proximal to the tibial plafond for males.

Sharma A, Scammell BE, Fairbairn KJ, Seagrave MJ, Game FL, Jeffcoate WJ.  Prevalence of calcification in the pedal arteries in diabetes complicated by foot disease.  Diabetes Care.  2010 May; 33(5): e66. (Pubmed ID#: 20427675)

WHY did the authors undertake this study?
The relationship between pedal complications and the development of medial arterial calcification (MAC) in diabetic patients is not well understood.  The aim of this study was to determine the prevalence of MAC in a group of diabetic patients with known pedal complications.

HOW did they attempt to answer this question?
The primary outcome measure of this study was identification of the presence of MAC (as identified by dorsal-plantar radiographic images) in a group of patients from a diabetic foot clinic.  Patients were included in the analysis if their diabetes was complicated by acute Charcot disease, osteomyelitis or an uncomplicated foot ulceration.

WHAT were the specific results?
The overall prevalence of MAC was 52.9% in the Charcot group, 66% in the osteomyelitis group and 54.3% in the uncomplicated foot ulceration group.  No statistically significant differences were identified in the prevalence of MAC between these groups.

HOW did the authors interpret these results?
From these results the authors concluded that the presence of MAC is likely in patients with diabetes, neuropathy and a source of local inflammation, but not necessarily a specific type of foot complication or disease process.

Let’s take a closer look at the topic of choosing an appropriate title for a research study.  In a recent “Editorial” for The Journal of Foot and Ankle Surgery, Dr. Malay correctly points out that keeping up with the medical literature can represent a “daunting” challenge given the sheer volume at which it is being produced.   He then takes the reader through his approach of rapidly reviewing a published article to see if it’s worth his complete attention.  Not surprisingly, the first thing he does is read the title of the article to see if the topic is something that interests him.  Now, we all know that you shouldn’t “judge a book by its cover”, but the title of an article should provide the reader with certain information about its content.

The title of our first reviewed article in this issue was “Safety of Ankle Trans-Syndesmotic Fixation”.  This title immediately caught my attention because of the word “safety”.   My brain quickly starting churning through different outcome measures that could used to measure some degree of patient “safety” with respect to the fixation of ankle fractures.  I was then surprised as I started reading through the abstract to find that the specific aim of the study was to define the relationship between the trans-syndesmotic screw and perforating branch of the peroneal artery.  This relationship didn’t fit with my expectation of the word “safety”. 

It’s not as though the title of this article was wrong, but it certainly left me with a different impression than what I was expecting.  A simple rule of thumb that I use to judge a title is to stick the words “What is…?” in front of the title.  If I can answer the question of “What is….?” by the time I get to the end of the article, then the title is providing me with a reasonable amount of information about the article’s content.  Using our first example, I can’t give you the answer to the question “What is the safety of ankle trans-syndesmotic fixation” based on the information provided.   The article simply didn’t provide me with that answer.

On the other hand, I could answer the question of “What is the prevalence of calcification in the pedal arteries in diabetes complicated by foot disease” by the end of our second reviewed article.  Compare these two titles and appreciate how much more information the second title is giving us critical readers.  Just based on the title of the second article I already know the primary outcome measure (calcification of pedal arteries), the population cohort (diabetic patients with foot disease) and the type of statistical analysis that the authors are going to perform (prevalence). 

Another seemingly silly thing that has always stuck with me with respect to titles is from way back in elementary school when I first heard about Sir Francis Bacon and the scientific method!   When we were learning about simple charts and graphs, a teacher told me that the best title for a graph was always “The Effect of X on Y”.  In other words, what the graph is really showing is the effect of some variable (whatever is on the x-axis) on some constant (whatever is on the y-axis).    This is usually a very safe fall-back in terms of titles in the podiatric literature because most of our studies fit this description.  Think about how many articles you’ve read that fit into the category of studying the effect of X (some surgical procedure) on Y (radiographic and clinical outcomes measures of a patient cohort).   And of course in this situation, the goal of the study is to determine “What is the effect of X on Y?”.