EXPAREL® (Long-Acting Liposomal Bupivacaine) Use for Popliteal Nerve Block in Postoperative Pain Control after Ankle Fracture Fixation.

EXPAREL® has been used successfully to prolong postoperative pain control when applied as a wound infiltrate. EXPAREL® has not yet been approved for use in regional anesthesia to prolong postoperative pain control. We conducted a clinical case series of 4 patients using EXPAREL® for sciatic blocks via the popliteal fossa approach. Our results suggested that there is a large degree of variability in response to the medication. These inconsistent results and the possibility of bimodal kinetics creating analgesic gaps as seen in two of our patients indicate that more studies with larger sample size are needed to better characterize these phenomena and determine if more consistent results can be obtained in a future clinical trial.

Determining the strongest orientation for "Lisfranc's screw" in transverse plane tarsometatarsal injuries: a cadaveric study.

UNLABELLED: The treatment of tarsometatarsal joint fracture-dislocations generally consists of realignment followed by stabilization with rigid internal fixation. The purpose of this study was to determine the strongest orientation for the "Lisfranc's screw" for repair of disruption of the articulation between the first and second metatarsals and the medial and intermediate cuneiforms. To this end, Lisfranc's ligament was sectioned in 6 pairs of fresh-frozen, human cadaver feet, after which a 3.5-mm partially threaded, cannulated screw was placed across the Lisfranc joint in 1 of 2 opposing directions. In one group, the screw was oriented in the more traditional medial cuneiform to second metatarsal base direction. In the other group, the screw was oriented from the second metatarsal base to the medial cuneiform. After fixation, each construct was pulled to transverse plane failure at the tarsometatarsal joint with a servohydraulic mechanical testing system. The overall force to failure was 157.04 +/- 54.79 N (range, 96.8-249.2 N). For the traditional medial cuneiform to second metatarsal base screw orientation group, the mean force to failure was 148.97 +/- 54.93 N, whereas for the second metatarsal base to medial cuneiform group the mean force to failure was 165.12 +/- 58.57 N, and this difference was not statistically significant (P = .2475). Although not statistically significantly different in regard to force to failure strength, the authors describe an alternative approach to the orientation of "Lisfranc's screw" for stabilization of the relationship of the medial cuneiform to the second metatarsal. LEVEL OF CLINICAL EVIDENCE: 5.

Evaluation and Perioperative Management of the Diabetic Patient.

Diabetes mellitus is a devastating disease that has reached epidemic proportions. The surgical patient with diabetes is at increased risk for developing complications when compared with patients without diabetes. A comprehensive preoperative work-up must be performed, including ancillary studies, with optimization of the patient's glucose levels during the perioperative period to decrease the chance of developing surgical complications. A multispecialty team approach for the care of patients with diabetes should be used to produce successful surgical outcomes.

Teaching during rounds.

Teaching rounds are a vital part of every residency program. Patient rounds provide an avenue to incorporate evidence-based medicine, current literature, and personal experiences into daily teaching while allowing residents to experience the doctor-patient relationship. Although time consuming, daily in-patient rounds are invaluable to any physician's training. This article discusses how to conduct well-organised, efficient patient rounds with maximum learning benefits for the residents. The daily protocol followed by the Podiatry Service at University Hospital, University of Medicine and Dentistry of New Jersey is also described. Conducting beneficial teaching rounds is an important aspect of a residency program when developing highly competent physicians.

In-training examinations.

In-training are one way to evaluate the residents during their training. Currently, the American Board of Podiatric Surgery supplies the examination. Various residency directors were questioned regarding its use and importance.

Capsular interposition for the Keller bunionectomy with the use of soft-tissue anchors.

The Keller procedure has been used during the past century for the treatment of first metatarsophalangeal joint pathology. Many modifications to the procedure have been made, including interposition of the joint capsule into the first metatarsophalangeal joint space. Capsular interposition is often the most difficult step in performing the Keller bunionectomy. This article describes a new, simplified technique for capsular interposition with the use of a dorsal capsular flap and soft-tissue anchors.

Perioperative management of pedal amputations.

When performing a pedal amputation, proper preoperative, intraoperative, and postoperative care is essential for a successful outcome. This article outlines proper perioperative management for the amputation patient. All patients require appropriate medical management and testing before any surgical procedure; however, preoperative planning specific for the amputation patient also is required to determine the appropriate level of amputation and to provide an optimal result. The surgeon always must remember that patients with more distal amputations have a decreased energy expenditure and better functional outcome compared with their more proximal counterparts. Appropriate psychological counseling and physical rehabilitation also should be initiated as early as possible for the patient to recover fully in a timely fashion.

Tendon balancing in pedal amputations.

Pedal amputations are necessary procedures performed by a foot and ankle surgeon that may lead to gross positional deformities of the foot. To achieve a plantigrade foot, proper balancing of the foot is required often through the use of tendon transfers and lengthening. This article describes the basic tendon transfers needed to achieve a successful outcome when performing various pedal amputations. A case is presented in which Achilles tendon lengthening was used to heal a forefoot ulcer. A full understanding of tendon function and transfer techniques is paramount for surgeons performing pedal amputations. By rebalancing the foot, patients are able to ambulate with custom shoes or bracing, and more proximal amputations, which can be physically and psychologically devastating, are prevented.

Pediatric heel pain.

Heel pain is a condition that is generally more common in the adult population. However, it is a condition that the foot and ankle specialist must be prepared to treat in pediatric patients. The insidious onset of heel pain in the pediatric patient can be an enigma to the foot and ankle specialist. Some of the more common etiologies for pediatric heel pain are discussed. The presenting signs and symptoms, as well as proper workup and treatment are discussed. Two case reports of unusual pediatric calcaneal fractures are also presented.

Strength of braided polyblend polyethylene sutures versus braided polyester sutures in Achilles tendon repair: a cadaveric study.

BACKGROUND: Various techniques may be used to repair Achilles tendon ruptures; however, we contend that using the strongest suture with the least amount of suture material is ideal. METHODS: To compare the strength of 2-0 FiberLoop (Arthrex Inc, Naples, Florida) and #2 Ethibond (Ethicon Inc, Somerville, New Jersey) suture materials in Achilles tendon repairs, 12 Achilles tendons were harvested from cadavers aged 18 to 62 years (median age, 42 years). The tendons were transected and repaired using a modified Krackow suture technique. All of the right limbs were repaired with 2-0 FiberLoop, and the contralateral side was repaired with #2 Ethibond. The specimens were mounted to a materials testing system, and the repairs were pulled to failure in an anatomical direction. RESULTS: The mean +/- SD yield loads of 2-0 FiberLoop and #2 Ethibond were 233 +/- 48 N and 134 +/- 34 N, respectively (P = .002). The mean +/- SD ultimate load of 2-0 FiberLoop was 282 +/- 58 N, and that of #2 Ethibond was 135 +/- 33 N (P < .001). The cross-sectional area of one pass of 2-0 FiberLoop was calculated to be 0.21 mm(2), and one pass of #2 Ethibond was 0.28 mm(2). CONCLUSIONS: The smaller-caliber 2-0 FiberLoop was significantly stronger than #2 Ethibond. This study suggests that there is no advantage to using the traditional larger suture material for Achilles tendon repairs; however, further clinical testing is needed to determine the optimal repair technique.