Anatomic Considerations Regarding the Placement of a Retrograde Intramedullary Fibular Screw.

The purpose of this study was to identify the ideal start site for a retrograde intramedullary fibular cortical screw based on its relationship to the surrounding soft tissue structures and to assess for damage to the surrounding soft tissue structures caused during placement of the screw. Four fresh frozen cadavers underwent fluoroscopic placement of a 3.5 mm cortical screw utilizing a standardized protocol. No damage to the peroneal tendons were noted in any cadaver with the foot in an inverted and plantarflexed position. The closest structure to the center of the screw head was the anterior talofibular ligament anteriorly (3.33 mm range: 3-4 mm) and the calcaneofibular ligament posteriorly (2.66 mm, range: 2-3 mm). Two screws violated the malleolar fossa medially and were noted to impinge on the lateral process of the talus. The ideal start site for a 3.5 mm intramedullary fibular screw is at the midline on the lateral radiograph and 3.0 mm lateral to the malleolar fossa on the AP radiograph. This avoids damage to the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) and prevents impingement on the lateral process of the talus. (Journal of Surgical Orthopaedic Advances 30(2):078-081, 2021).

Outcomes of Below-the-Knee Amputations for Chronic Lower Extremity Pain.

The study evaluated the physical,mental, and functional outcomes following below-the-knee amputation (BKA) for management of chronic, debilitating lower extremity pain. The hypothesis was that patients who undergo a BKA to alleviate chronic pain achieve a greater level of function, experience decreased pain, and benefit from improved health-related quality of life. Patients who received a BKA attended an orthopaedic clinic and completed questionnaires examining their overall health, functional status, mental health, and pain. Thirty-seven patients were identified as eligible for study participation; 15 agreed to participate. Although most participants continued to experience pain in their residual limb after BKA, they reported their pain decreased to a manageable level. Participants experienced a statistically significant improvement in their perceived physical health. The authors believe a BKA for chronic pain is a reasonable treatment option for patients who continue to experience lower extremity pain after failed medical and surgical management of chronic pain. (Journal of Surgical Orthopaedic Advances 26(4):200-205, 2017).

Talar neck fractures: a systematic review of the literature.

Considerable controversy surrounds the management of talar neck fractures regarding the rate of post-traumatic arthrosis, secondary procedures, avascular necrosis, and the effect of the interval to surgery on these variables. A data search using PubMed was performed with the keywords "talus" and "fracture." The search found 1280 studies. Ultimately, 21 reports involving 943 talar neck fractures were analyzed. Data concerning open fractures, the interval to surgery and its relationship to the incidence of avascular necrosis, and the rates of malunion and nonunion, post-traumatic arthrosis, secondary salvage procedures, and functional outcomes were collected and analyzed. The variables examined were not uniformly reported in all studies. The overall rate of avascular necrosis was 33%, with no demonstrated relationship between the interval to surgery and the rate of avascular necrosis. Malunion occurred approximately 17% of the time, with nonunion occurring approximately 5% of the time. Post-traumatic arthrosis occurred in 68% of patients, although secondary salvage procedures were only performed in 19% of patients. Functional outcomes were difficult to assess, given the variability of reported outcomes and unvalidated measures. The optimal management of talar neck fractures has yet to be determined. Although the present review has improved understanding of these difficult fractures, additional studies that use validated outcomes measures are warranted to determine the effect of delayed surgery on final outcomes and optimal treatment methods.

First metatarsophalangeal arthrodesis: a biomechanical comparison of three fixation constructs.

First metatarsophalangeal joint arthrodesis is utilized in the treatment of severe arthritis and hallux valgus. Successful fusion relies on limiting motion at the fusion site and may be achieved through numerous methods. Use of locking plates has recently generated considerable interest, but whether they provide any biomechanical advantage over other available constructs is unclear. Utilizing cyclic loading intended to mimic early weight bearing, the stiffness of three fixation methods for first metatarsophalangeal arthrodesis was compared using Sawbones. The one-third tubular plate completed 1.8 and 2.4 times more cycles before failure than the X-type locking plate or crossed screws, respectively. No difference was detected in cycles to failure between the X-type locking plate and crossed screws. One-third tubular plate mean stiffness was 49% greater than crossed screws at all cycles and greater than X-type locking plate by an average of 25%, beginning at cycle 50.

Vascular injury associated with extremity trauma: initial diagnosis and management.

Vascular injury associated with extremity trauma occurs in <1% of patients with long bone fracture, although vascular injury may be seen in up to 16% of patients with knee dislocation. In the absence of obvious signs of vascular compromise, limb-threatening injuries are easily missed, with potentially devastating consequences. A thorough vascular assessment is essential; an arterial pressure index <0.90 is indicative of potential vascular compromise. Advances in CT and duplex ultrasonography are sensitive and specific in screening for vascular injury. Communication between the orthopaedic surgeon and the vascular or general trauma surgeon is essential in determining whether to address the vascular lesion or the orthopaedic injury first. Quality evidence regarding the optimal fixation method is scarce. Open vascular repair, such as direct repair with or without arteriorrhaphy, interposition replacement, and bypass graft with an autologous vein or polytetrafluoroethylene, remains the standard of care in managing vascular injury associated with extremity trauma. Although surgical technique affects outcome, results are primarily dependent on early detection of vascular injury followed by immediate treatment.

Smartphone Applications for Assessing Ankle Range of Motion in Clinical Practice.

BACKGROUND: Measuring ankle range of motion (ROM) following injury or intervention is necessary for monitoring recovery as well as for calculating permanent impairment ratings in workers' compensation cases. In recent years, smartphone application developers have created applications (apps) that emulate ROM measurement tools like the universal goniometer. This study assessed the correlation between smartphone ROM measurements and universal goniometer measurements, as well as the reliability and usability of these apps in clinical practice. METHODS: Three raters used the Goniometer app (Gonio), Clinometer app (Clino), DrGoniometer app (DrG), and a universal goniometer (UG) to assess the ankle ROM in plantarflexion and dorsiflexion of 24 patients with ankle pathology. Each patient completed a survey on the usability of the apps. RESULTS: Lin's concordance correlation coefficient test showed moderate correlation between the smartphone and UG measurements (Lin's correlation coefficient [rLC] = 0.931, 95% confidence interval [CI] = 0.911-0.946 for UG-Gonio; rLC = 0.908, 95% CI = 0.881-0.929 for UG-Clino; rLC = 0.935, 95% CI = 0.915-0.950 for UG-DrG). A 2-way mixed model showed good to excellent interrater reliability for each app for plantarflexion and dorsiflexion (ICCp = 0.836, ICCd = 0.912, P < .001 for Gonio; ICCp = 0.788, ICCd = 0.893, P < .001 for Clino; ICCp = 0.777, ICCd = 0.897, P < .001 for DrG). Most participants surveyed were very comfortable with having their ankle ROM measured by a smartphone. CONCLUSION: Smartphone apps may be a more convenient way to measure ankle ROM than UG. Physicians can use these apps to measure a patient's ROM in clinic, a patient could send a picture of his or her dorsiflexed or plantarflexed ankle to the physician to remotely track ROM, or a patient could measure his or her own ROM at home using a personal smartphone. LEVEL OF EVIDENCE: Level IV, case series.

Finding Value in Surgical Didactics: Longitudinal Resident Feedback From Case-Based and Traditional Lectures in an Orthopaedic Residency.

OBJECTIVE: To evaluate orthopedic resident perceptions of a didactic curriculum presented in traditional and case-based formats. DESIGN: Prospective cohort study using anonymous web-based survey after each conference evaluating resident perceptions of faculty participation, didactic delivery, content, and overall conference value. Conferences were structured as primarily case-based or traditional lecture. Logistic analysis was performed to determine factors predictive of rating a conference as valuable time spent. SETTING: Orthopedic residency training program at single institution over an academic year. PARTICIPANTS: Orthopedic residents in postgraduate training year 1 to 5 attending mandatory didactic conference. RESULTS: Cased-based conferences received higher Likert ratings on residents' perception of faculty participation, instructor delivery, and improvement in topic understanding when compared to traditional lecture-based conferences (p < 0.0001 for each factor). Residents also were more likely to rate case-based conferences as valuable time spent (p < 0.0001). In our logistic model, factors associated with a negative likelihood of rating a conference as valuable were lecture format (odds ratio [OR] = 0.155, 95% CI: 0.115-0.208), PGY-2 level presenter (OR = 0.288, 95% CI: 0.169-0.490), and PGY-3 level presenter (OR = 0.433, 95% CI: 0.269-0.696). Timing in the year, surgical subspeciality, and conference identity were not significant predictors of conference value rating. CONCLUSIONS: Longitudinal resident feedback demonstrates highly favorable resident perceptions toward case-based formats in didactic sessions. Junior levels residents are not perceived as effective as senior residents and faculty in presenting material in either format. These methods allow for a dynamic approach to identifying strengths and weaknesses in a resident curriculum as a well as a means for more focused and real-time improvements.

Complex regional pain syndrome (reflex sympathetic dystrophy).

The management of CRPS can be approached using objective criteria in a logical and systematic fashion. Frustration during treatment is common because: (1) the pathophysiology of CRPS is incompletely understood, (2) there is significant variation in presentation due to disparate premorbid anatomy and physiology, and (3) the natural history may be affected by incomplete treatment. Therapeutic efforts that should be effective may fail, and a trial-and-error approach to treatment is often mandatory. Early recognition of CRPS and prompt intervention, however, provide the best opportunity for clinical improvement.

Stabilization of Lisfranc joint injuries: a biomechanical study.

BACKGROUND: Lisfranc joint injuries are often misdiagnosed, leading to significant morbidity. Methods for anatomic reduction of the tarsometatarsal joint include closed reduction with casting or surgical stabilization with either Kirschner wires and/or cortical screw fixation. Controversy exists as to which fixation technique offers optimal stability. In the present study, the biomechanical stability of three fixation methods was tested: (1) four Kirschner wires, (2) three cortical screws plus two Kirschner wires, and (3) five cortical screws. METHODS: Ten matched pairs of fresh-frozen cadaveric feet were dissected to their ligamentous and capsular elements. The tarsometatarsal ligaments were completely transected to replicate a Lisfranc dislocation; the "injury" was reduced and stabilized using one of the three methods. Biomechanical studies were performed by applying a 100-N cyclic load physiologically distributed to the plantar aspect of the metatarsal heads. Displacement and force measurements were taken from the first and fifth metatarsal heads. Average stiffness of each construct was calculated from the force displacement curves. RESULTS AND CONCLUSIONS: Method 2 provided significantly more stability than Kirschner wire fixation. Method 3 created more stiffness than method 2 at the medial portion of the foot; no statistical difference between the two methods was evident at the lateral foot. CLINICAL RELEVANCE: Cortical screw fixation provides a more rigid and stable method of fixation for Lisfranc injuries as compared to Kirschner wire fixation. This fixation method allows maintenance of anatomic reduction and possibly earlier mobilization with a decreased risk of posttraumatic arthrosis.

Innovations in the management of hip fractures.

Hip fractures include fractures of the head, neck, intertrochanteric, and subtrochanteric regions. Head fractures commonly accompany dislocations. Neck fractures and intertrochanteric fractures occur with greatest frequency in elderly patients with a low bone mineral density and are produced by low-energy mechanisms. Subtrochanteric fractures occur in a predominantly strong cortical osseous region that is exposed to large compressive stresses. Implants used to address these fractures must accommodate significant loads while the fractures consolidate. Complications secondary to hip fractures produce significant morbidity and include infection, nonunion, malunion, decubitus ulcers, fat emboli, deep venous thrombosis, pulmonary embolus, pneumonia, myocardial infarction, stroke, and death.

Mechanical properties of lower limb dermis following static and cyclic compression.

Lower extremity amputations and foot ulcers are complications associated with diabetes, and have been shown to affect diabetic African Americans (AA) three times as often as diabetic non-Hispanic Whites (NHW). Possible causes for the increased risk include ethnic differences in structure and function within the dermis of the lower extremity. Testing this hypothesis requires studying the mechanical properties of skin from different ethnic groups with and without the diagnosis of noninsulin-dependent diabetes. The purpose of this study was to develop a testing method to investigate changes in tensile mechanical properties resulting from static and cyclic compression of dermis harvested from patients undergoing lower extremity amputations. Full thickness dermal samples were obtained from 15 patients undergoing below-knee amputations. Sections of each sample were conditioned with a compressive static pressure (170 mmHg) or cyclic pressures (110-170 mmHg) for 4 hours to elicit collagen bundle remodeling. Skin samples were then tested in tension to obtain sub-plastic stress vs. strain mechanical behavior. Length of the stress-strain toe-region was examined to quantify the effect of collagen bundle remodeling. Toe-region mean lengths were 0.141±0.041, 0.146±0.034, and 0.164±0.064 strains for the control, cyclic, and statically compressed samples respectively (p>.05). These results suggest that the preconditioning regimes did not produce sufficient collagen remodeling to affect the tensile properties of full-thickness dermis. Future work will examine histology from each specimen to identify microstructural features associated with this trend.

Effect of selective sensory denervation on fracture-healing: an experimental study of rats.

BACKGROUND: Interactions between the peripheral nervous system and the healing skeleton are poorly understood. Various clinical observations suggest that the nervous system interacts with and promotes fracture-healing. The purpose of this study was to examine the effect of selective sensory denervation on fracture-healing. METHODS: Fifty-one Sprague-Dawley rats underwent unilateral placement of an intramedullary rod followed by creation of a standardized femoral fracture. One group of these rats underwent sensory denervation by means of a localized capsaicin injection, and the other did not. Subgroups were allocated for analysis of mRNA expression of collagen I and II and osteocalcin at three, seven, and fourteen days after the fracture. Additionally, histological examination was performed at four weeks; micro-computed tomography, at five weeks; and biomechanical testing, at six weeks. RESULTS: The sensory-denervated group had significantly less collagen-I upregulation than the sensory-intact group at three days after the fracture (difference in means, forty-four-fold [95% confidence interval = 22.7 to 65.5-fold]; p < 0.001) and significantly less collagen-II upregulation at seven days after the fracture (difference in means, ninefold [95% confidence interval = 4.3 to 13.8-fold]; p < 0.001). In the sensory-denervated group, the fracture callus had a significantly larger cross-sectional area (difference in means, 15.6 mm(2) [95% confidence interval = 0.78 to 30.5 mm(2)]; p = 0.043) and was less dense. Biomechanical testing revealed that sensory denervation significantly decreased the load to failure (difference in means, 28.7 N [95% confidence interval = 1.2 to 56.2 N]; p = 0.022). CONCLUSIONS: Sensory denervation negatively affects fracture-healing. These results offer insight into the nerve-bone interaction following injury.