Is there a tolerance for extension of the first metatarsal after the Lapidus procedure? A clinical, functional, and hindfoot radiographic analysis.

PURPOSE: Based on the tripod concept of load distribution, our study aimed to evaluate whether a slight extension of first metatarsal (M1) that may occur after the Lapidus procedure (LP) could alter the radiographic measurements of the hindfoot and influence clinical and functional outcomes. METHODS: Twenty-five patients (27 feet) were reviewed. Hindfoot radiographic analysis was based on seven measurements. Clinical and functional outcomes were evaluated with self-reported questionnaires. Transfer metatarsalgia was also assessed. Correlation analysis was performed according to variations of the studied variables. RESULTS: The average extension of the M1 was 4.26 degrees (p < 0.001). None of the hindfoot radiographic measurements changed significantly (p = 0.13, p = 0.50, p = 0.19, p = 0.70, p = 0.11, p = 0.36, p = 0.83). Patients improved on most questionnaires (p < 0.001). None presented transfer metatarsalgia. No correlation between M1 extension and clinical and functional outcomes was found. CONCLUSION: Possibly there is a tolerance of M1 extension in which it does not alter the radiographic measurements of the hindfoot, overload the lesser metatarsals, or compromise clinical and functional outcomes.

Ankle instability in pediatric and adolescent patients diagnosed with lateral malleolus avulsion fracture: Analysis of clinical and functional outcomes of ligament injury repair surgery.

BACKGROUND: Some children and adolescents can develop persistent pain and instability following inversion injuries of the ankle. In these cases, imaging exams could reveal small bone fragments distal to the lateral malleolus. For these patients, regular conservative treatment may not be successful, requiring additional management, which can include surgical treatment. This study aimed to present the short-to-midterm functional and clinical outcomes of a series of 12 pediatric and adolescent patients who underwent ligament repair surgery due to chronic instability associated with the presence of osseous components in the lateral ligaments. METHODS: A review of 12 patients treated with surgical ligament reconstruction of the ankle was evaluated. Clinical and functional evaluations were based on comparing the Visual Analogue Scale (VAS), AOFAS ankle-hindfoot score, and residual symptoms before and after the surgical intervention. RESULTS: Before the reconstructive approach, the mean VAS was 2.41 and the mean AOFAS score was 74.16. After the procedure, the standard VAS declined to zero, and the AOFAS score was 100 in all patients. The mean follow-up was 6.33 months. CONCLUSION: The surgical approach in children and adolescents with symptomatic ankle instability due to the presence of osseous fragments after an initial inversion trauma provided adequate clinical and functional results at short-to-midterm follow-up. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Functional outcomes and rates of return to sport activities in a non-athlete population after the open Brostrom-Gould repair: a seven-year follow-up.

INTRODUCTION: After an ankle sprain, up to 20% of patients may develop chronic lateral ankle instability (CLAI) requiring surgical treatment. The objective of this study was to investigate the functional outcomes and rates of return to sport activities in a cohort of non-athlete patients with chronic lateral ankle instability (CLAI) who underwent the opened Brostrom-Gould technique (BGT). MATERIALS AND METHODS: Seventy-nine patients (seventy-nine feet) from three different centers undergoing BGT were reviewed. For clinical and functional analysis, the AOFAS ankle-hindfoot scale was applied and rates of return to sport activities were assessed. Correlation of Δ-AOFAS and rates of return to sport activities with all variables analyzed was performed. RESULTS: Mean AOFAS score improved from 64.6 to 97.2 (p < 0.001). Sixty-one (77.2%) returned to preinjury activities and 18 (22.8%) changed to a lower-level modality. Symptoms of instability were related to Δ-AOFAS (p = 0.020). Change in the sport activity was related to pain and symptoms of instability (p = 0.41 and p < 0.001). CONCLUSION: Recreational athlete patients who underwent the BGT demonstrated excellent functional outcomes after a mean follow-up of 7 years. Residual pain and symptoms of instability after surgery were the main complaints associated with limitations in physical activities.

A comparative analysis of clinical, functional and radiographic outcomes of patients with and without fusion between the first and second metatarsals after the lapidus procedure.

BACKGROUND: The aim of this study was to compare the clinical, functional and radiographic outcomes in patients who underwent the original Lapidus procedure (OLP) with fusion and undesired non-fusion between the first (M1) and second (M2) metatarsals. METHODS: A retrospective and comparative analysis of 29 patients (38 feet) who underwent the OLP was performed. They were divided in two groups: (1) 23 feet in which fusion occurred and (2) 15 with undesired non-fusion. Clinical and functional data were assessed with the VAS for pain, AOFAS, LEFS and SF-12. SF-12 comprises physical and mental health scales (PCS-12 and MCS-12). Radiographic parameters assessed were bony and soft tissue forefoot widths (BSFW), intermetatarsal-angle (IMA) and HV-angle (HVA). RESULTS: Separately, the groups presented significant improvements in all questionnaires (p < 0.001), except on MCS-12 (fusion p = 0.08 and non-fusion p = 0.27). When comparing both groups, patients with fusion had higher AOFAS scores (p < 0.05). Both groups presented the same improvements on BSFW, IMA and HVA (p = 0.09, p = 0.16, p = 0.52 and p = 0.63). CONCLUSION: Excellent results were observed, even when without fusion between M1 and M2. Patients who evolved with fusion between the M1 and M2 showed greater improvements in the AOFAS score. LEVEL OF EVIDENCE: III, retrospective comparative study.

Impact of forefoot width variation on clinical and functional outcomes following the Lapidus procedure.

PURPOSE: This study aimed to evaluate the effect of variations in bony and soft tissue foot widths on clinical and functional outcomes after hallux valgus correction with the Lapidus procedure. METHODS: Forty-three feet in 35 patients with a mean follow-up of 18.5 months undergoing the LP were reviewed. Clinical and functional data were assessed with the VAS for pain, AOFAS Scale, LEFS and SF-12 health survey, which is divided into physical and mental health composite scales (PCS-12 and MCS-12). Radiographic analysis of forefoot width was based on bony and soft tissue limits. Intermetatarsal-angle and HV-angle were also assessed. RESULTS: Bony width changed significantly from 95.5 mm to 84.2 mm (11.8%) and soft tissue width from 107.12 mm to 100.84 mm (5.86%) (p < 0.001). IMA and HVA improved significantly. Significant clinical and functional improvements were observed, except in MCS-12. In simple linear regression, correlation was found between variations of bony width with Δ-AOFAS and Δ-PCS-12, meaning that as the forefoot narrows, their values increase (p = 0.02 and p = 0.005, respectively). It was also related to Δ-IMA, meaning that the forefoot narrows as these parameters improve (p < 0.001 and p < 0.001). Soft tissue width was related to Δ-PCS-12 and Δ-AIM. In multiple linear regression, the strongest correlation was between bony width variation and Δ-IMA (p = 0.029, r2 = 0.22). CONCLUSION: Forefoot narrowing was correlated with improved clinical and functional outcomes, as measured by AOFAS and PCS-12. In addition, correction of the radiographic parameters, mainly IMA, reflected on a significant decrease in the forefoot width.

Correlation of first metatarsal sagittal alignment with clinical and functional outcomes following the Lapidus procedure.

BACKGROUND: The purpose of this study was to evaluate the effect of the variation of the first metatarsal (M1) sagittal alignment after the Lapidus procedure (LP) on clinical and functional outcomes, and transfer metatarsalgia. METHODS: Twenty-nine patients who underwent a LP, with a mean follow-up of 20 months, were reviewed. Radiographic, clinical and functional measurements were compared. Clinical and functional questionnaires applied were the visual analogue scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) scale, lower extremity functional scale (LEFS) and SF-12, which is divided in physical (PCS-12) and mental-health (MCS-12) scales. Radiographic analysis of M1 sagittal alignment was based on the first metatarsal declination angle (FMDA) and Meary Angle (MA). Intermetatarsal angle (IMA) and hallux valgus angle (HVA) were also measured. RESULTS: FMDA, IMA and HVA showed significant variation, but MA did not. Clinical and functional improvements were observed, except in MCS-12. No patient developed transfer metatarsalgia. A direct correlation was found between Δ-FMDA with Δ-PCS-12 and Δ-LEFS, meaning that excessive M1 dorsiflexion as measured by FMDA led to a decrease in PCS-12 and LEFS. Patients with Δ-FMDA of up to 3.2° of dorsiflexion were those who had significant improvements. CONCLUSION: Dorsiflexion of M1 can lead to decreased outcomes as measured by PCS-12 and LEFS. However, satisfactory outcomes can be obtained even with some dorsal deviation of the M1. LEVEL OF EVIDENCE: IV, retrospective case series.

Is first metatarsal shortening correlated with clinical and functional outcomes following the Lapidus procedure?

OBJECTIVE: To correlate first metatarsal (M1) shortening with transfer metatarsalgia, and clinical and functional outcomes in patients who underwent the Lapidus procedure (LP). MATERIALS AND METHODS: A retrospective review of 29 patients who were submitted to the LP for HV correction. The average follow-up was 20 months. M1 length was analyzed using the Relative First Metatarsal Length (RML) measurement. Intermetatarsal angle (IMA) and hallux valgus angle (HVA) were also measured. Clinical and functional analyses were based on the visual analogue scale (VAS), Lower Extremity Functional Scale (LEFS), and Short-form 12 (SF-12) health survey. SF-12 is divided into physical (PCS-12) and mental health (MCS-12) composite scales. Transfer metatarsalgia was diagnosed by the clinical exam. Radiographic, clinical, and functional outcomes were compared using paired Wilcoxon's and Student's t tests. Inter-observer reliability of RML measures was calculated using Intraclass Correlation Coefficients (ICC). The correlation between RML and the clinical and functional questionnaires was assessed with the Spearman's Rho test. RESULTS: There was a significant M1 shortening of 2.3 mm (p < 0.05), with mean preoperative RML of 3 mm and mean post-operative of 5.3 mm. None of the patients evolved with transfer metatarsalgia. ICC of the RML measures presented excellent reliability. IMA and HVA showed improvements (p < 0.05). Clinical and functional improvements were observed in all questionnaires applied, except in the MCS-12. In the linear regression, RML was inversely correlated to LEFS (p < 0.05), which means that LEFS scores increased as RML measurements decreased. CONCLUSION: The present study demonstrated that M1 shortening led to a decreased LEFS following the LP.

Clinical outcomes of isolated acute instability of the syndesmosis treated with arthroscopy and percutaneous suture-button fixation.

INTRODUCTION: To present the short- to midterm clinical outcomes of a series of patients with isolated acute syndesmosis instability treated with arthroscopy and percutaneous suture-button fixation. MATERIALS AND METHODS: A review of 17 patients treated through the arthroscopic approach. The mean age of the patients was 27.8 years and the mean follow-up was 31.5 months. Clinical and functional evaluations were based on the VAS, AOFAS ankle-hindfoot score and time of return to preinjury level of activities. Imaging analysis was performed with stress radiographs, MRI and CT scan with stress. RESULTS: The average VAS was 0.5 and the mean AOFAS score was 95.5. Out of the 17 patients, 15 were able to return to their preinjury level of activities. The mean time of return to activities was 5.06 months. CONCLUSION: Arthroscopic approach and percutaneous suture-button fixation provided satisfactory clinical and functional results for selected patients with ASI at short- to midterm follow-up. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Rotational biplanar Chevron osteotomy.

INTRODUCTION: The Chevron osteotomy is a reliable and popular osteotomy for treating hallux valgus worldwide. Many modifications have been described, but none of them address the rotational deformity of the first metatarsal. The objective of this study is to describe a variation of biplanar Chevron osteotomy which can address first metatarsal rotation when necessary. METHODS: The indications for the Rotational Biplanar Chevron Osteotomy (RBCO) are mild to moderate hallux valgus deformity associated with hallux pronation related to internal rotation of the first metatarsal bone. We describe a technique that uses a medial based wedge parallel to the plantar limb of the osteotomy in order to make the distal fragment free to correct rotation. RESULTS: The more recent concern about hallux valgus surgery is the very interesting concept that this deformity really occurs in three different planes, and we may have mistreated the rotation component with our current techniques. Many authors have revisited many common techniques in order to adapt them to correct metatarsal pronation. To our best knowledge, this is the first paper to describe a modification of the Chevron osteotomy to address the rotation of the first metatarsal. CONCLUSION: We can conclude that the rotational biplanar Chevron osteotomy can be an useful tool in the treatment of mild hallux valgus associated with metatarsal pronation.

Evaluation of Posterior Cruciate Ligament and Intercondylar Notch in Subjects With Anterior Cruciate Ligament Tear: A Comparative Flexed-Knee 3D Magnetic Resonance Imaging Study.

PURPOSE: To determine if posterior cruciate ligament (PCL) and intercondylar notch (IN) morphometries and volumetrics act as risk factors for anterior cruciate ligament (ACL) tears. METHODS: A prospective case-controlled magnetic resonance imaging (MRI) study was conducted with subjects presenting noncontact knee injuries. Exclusion criteria were previous surgery, PCL tear, osteoarthritis, tumors, or infectious and inflammatory conditions. All participants underwent a flexed-knee 3-dimensional (3D) magnetic resonance imaging (MRI) to uniformly straighten PCL. MR images were independently reviewed by 2 radiologists and assessed for 2D and 3D measurements (bicondylar width; IN angle, depth, width, and cross-sectional area; PCL width, thickness, and cross-sectional area; and IN and PCL volumes). Clinical profiles were tabulated and subjects were divided into cases (ACL tear) and controls (without ACL tear). RESULTS: The study was composed of 50 cases versus 52 controls (N = 102), with a mean age of 36.8 years. There was no difference between groups (P > .05) regarding age, gender, body mass index, time from injury, Tegner score, flexion angle, limb side, intensity of injury, or familial or opposite limb history of tear. Agreement between readers ranged from substantial to almost perfect. Subjects with ACL tear presented with lower IN width, lower IN minus PCL widths, lower Notch Width Index, higher PCL/IN width proportion, higher PCL thickness, lower IN depth minus PCL thickness, and higher PCL thickness/IN depth proportion (P < .05). Moreover, higher PCL/IN cross-sectional area proportion, higher PCL volumes (OR = 9.01), and higher PCL/IN volume proportion were also found in cases. CONCLUSIONS: Our study shows that subjects with ACL tears present not only reduced IN but also larger PCL dimensions. These findings, isolated and combined, and especially PCL volume, might be suggestive as risk factors for ACL tears owing to the reduction of its space inside the IN. LEVEL OF EVIDENCE: Level III, comparative group.

Use of life cycle assessment to evaluate environmental impacts associated with the management of sludge and biogas.

Upflow anaerobic sludge blanket (UASB) reactors used in sewage treatment generate two by-products that can be reused: sludge and biogas. At the present time in Brazil, most of this resulting sludge is disposed of in sanitary landfills, while biogas is commonly burned off in low-efficiency flares. The aim of the present study was to use life cycle assessment to evaluate the environmental impacts from four different treatment and final destination scenarios for the main by-products of wastewater treatment plants. The baseline scenario, in which the sludge was sanitized using prolonged alkaline stabilization and, subsequently, directed toward agricultural applications and the biogas destroyed in open burners, had the most impact in the categories of global warming, terrestrial ecotoxicity, and human non-carcinogenic toxicity. The scenario in which heat resulting from biogas combustion is used to dry the sludge showed significant improvements over the baseline scenario in all the evaluated impact categories. The recovery of heat from biogas combustion decreased significantly the environmental impact associated with global warming. The combustion of dried sludge is another alternative to improve the sludge management. Despite the reduction of sludge volume to ash, there are environmental impacts inherent to ozone formation and terrestrial acidification.

The Effect of Different Bone Marrow Stimulation Techniques on Human Talar Subchondral Bone: A Micro-Computed Tomography Evaluation.

PURPOSE: To evaluate morphological alterations, microarchitectural disturbances, and the extent of bone marrow access to the subchondral bone marrow compartment using micro-computed tomography analysis in different bone marrow stimulation (BMS) techniques. METHODS: Nine zones in a 3 × 3 grid pattern were assigned to 5 cadaveric talar dome articular surfaces. A 1.00-mm microfracture awl (s.MFX), a 2.00-mm standard microfracture awl (l.MFX), or a 1.25-mm Kirschner wire (K-wire) drill hole was used to penetrate the subchondral bone in each grid zone. Subchondral bone holes and adjacent tissue areas were assessed by micro-computed tomography to analyze adjacent bone area destruction and communicating channels to the bone marrow. Grades 1 to 3 were assigned, where 1 = minimal compression/sclerosis; 2 = moderate compression/sclerosis; 3 = severe compression/sclerosis. Bone volume/total tissue volume, bone surface area/bone volume, trabecular thickness, and trabecular number were calculated in the region of interest. RESULTS: Visual assessment revealed that the s.MFX had significantly more grade 1 holes (P < .001) and that the l.MFX had significantly more poor/grade 3 holes (P = .002). Bone marrow channel assessment showed a statistically significant increase in the number of channels in the s.MFX when compared with both K-wire and l.MFX holes (P < .001). Bone volume fraction for the s.MFX was significantly less than that of the l.MFX (P = .029). CONCLUSIONS: BMS techniques using instruments with larger diameters resulted in increased trabecular compaction and sclerosis in areas adjacent to the defect. K-wire and l.MFX techniques resulted in less open communicating bone marrow channels, denoting a reduction in bone marrow access. The results of this study indicate that BMS using larger diameter devices results in greater microarchitecture disturbances. CLINICAL RELEVANCE: The current study suggests that the choice of a BMS technique should be carefully considered as the results indicate that smaller diameter hole sizes may diminish the amount of microarchitectural disturbances in the subchondral bone.

Autologous osteochondral transplantation for osteochondral lesions of the talus in an athletic population.

PURPOSE: To assess clinical outcomes and return to sport in an athletic population treated with autologous osteochondral transplantation (AOT) for osteochondral lesions of the talus. METHODS: A total of 36 patients were included in this retrospective study including 21 professional athletes and 15 amateur athletes who participated in regular moderate- or high-impact athletic activity. All patients underwent autologous osteochondral transplantation of the talus under the care of a single surgeon. At a mean follow-up of 5.9 years, patients were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) scoring system. All patients also received pre-operative MRI with the follow-up MRI performed at 1 year and underwent assessment of return to athletic activity. RESULTS: The overall AOFAS score improved from 65.5 (SD ± 11.1) to 89.4 (SD ± 14.4) (p = 0.01). At a final follow-up, 90% of professional athletes (19 of 21) were still competing in athletic activity or still able to participate in unrestricted activity. Of the recreational athletes, 87% (13 of 15) had full return to pre-injury activity levels, while two (13%) returned to activity with restrictions or reduced intensity. MRI showed cystic change in 33% of patients post-operatively; however, this did not appear to affect outcomes (n.s.). Donor site symptoms were seen in 11% of the cohort at final follow-up, despite high function at donor knee. CONCLUSION: The results of our study indicate that AOT procedure is able to achieve good outcomes in an athletic population at a midterm follow-up. LEVEL OF EVIDENCE: Retrospective case series, Level IV.

Inadequate Purchase in the Proximal Tendon Stump Using the Percutaneous Achilles Repair System: A Technical Tip.

Minimally invasive approaches for the Achilles tendon have emerged as viable alternatives for acute Achilles ruptures, with several potential benefits in comparison to the open approach. Occasionally, proper purchase in the proximal tendon stump is not achieved due to severe degenerative disease of the tendon. In this article, we present a technique in which a small accessory incision is used during percutaneous Achilles repair in order to pass the sutures in a more proximal and healthy area of the tendon. This technique is useful for situations in which adequate tendon grasp is not obtained, avoiding the need of conversion to an open approach.Level of Evidence: Level V: Expert opinion.

Intraoperative Technical Tips to Improve Fusion Between the First and Second Metatarsals in the Original Lapidus Procedure.

The modified Lapidus procedure (MLP), which consists of fusion between the first metatarsal (M1) and medial cuneiform, has been widely performed with satisfactory clinical outcomes, but it has a variable nonunion rate ranging between 4% and 10% and loss of correction in up to 5.8% of the cases. Excessive motion around the site of tarsometatarsal arthrodesis, specially at the intercuneiform joint, is probably the reason. The original Lapidus procedure (OLP), which includes fusion of the M1 to second metatarsal (M2), may be beneficial in preventing nonunion and recurrence. The objective of this study was to describe intraoperative technical tips in the OLP to improve M1 to M2 fusion, which may prevent complications. Since the Lapidus procedure continues to gain popularity, it is the authors opinion that the OLP requires special attention because it is a more technically demanding surgery compared to the MLP.Level of Evidence: Level V: Expert opinion.

Acute ankle injuries: association between sprain severity and ancillary findings.

Miranda et al. reported a correlation between the significance of injuries to osseous, chondral, tendon, and ligamentous tissues in participants with low-grade versus high-grade acute ankle sprains. They demonstrated that participants with high-grade ankle sprains presented with shorter calcaneonavicular distances and increased rates of structural abnormalities compared to those with low-grade sprains. Special attention should be paid to acute ankle sprains in emergency settings to avoid failure in detecting severe injuries that could lead to chronic pain, impairment, or instability. Participants presenting acute ankle sprains (<15 days) were divided into low-grade versus high-grade sprain,according to the presence of a complete tear in at least one component of lateral ligament complex. High-grade ankle sprains group presented increased rates of medial malleolus bone bruise, deltoid ligament tears,extensor retinaculum lesions, and articular effusion. The calcaneonavicular distance was statistically shorter in patients with high-grade sprains (median, 3.0mm) when compared to those with low-grade sprains (median, 4.0mm) Objective: To correlate the significance of osseous, chondral, tendon, and ligamentous injuries with anatomical variations in low-grade versus high-grade acute ankle sprains. METHODS: We retrospectively identified the magnetic resonance imaging findings of acute ankle sprains (<15 days). Participants with a history of previous sprains, arthritis, tumors, infections, or inflammatory conditions were excluded. Images were independently evaluated by two musculoskeletal radiologists and assessed for osseous, chondral, tendon, and ligamentous injuries and anatomical variations. Participants were divided into low-grade versus high-grade sprain groups, according to the presence of a complete tear in at least one component of the lateral ligament complex. RESULTS: The final study group comprised 100 magnetic resonance images (mean age, 36 years), the majority of males (54%), the right ankle (52%), and a mean sprain duration of 5 days. Participants with high-grade sprains presented with increased rates of medial malleolus edema (p<0.001), moderate and large articular effusions (p=0.041), and shorter calcaneonavicular distance (p=0.008). Complete tears of the anterior talofibular ligament and calcaneofibular ligaments were observed in 100% and 51.2% of the participants in the High-Grade Group, respectively. The deltoid ligament complex was partially torn in this group (55.8% versus 8.8%, p<0.001). Extensor tendon retinaculum lesions occurred significantly more frequently in this group (41.9%) compared to the overall study population (23%) (p<0.001). CONCLUSION: Participants with high-grade ankle sprains presented with shorter calcaneonavicular distances and increased rates of medial malleolus edema, deltoid complex partial tears, extensor retinaculum lesions, and articular effusion.

Subungual Glomus Tumor of the Hallux A Report of 4 Cases.

This study reports the clinical outcomes and evolution of 4 patients with subungual glomus tumor (GT) of the hallux treated with tumor excision. Preoperatively, all patients had pain of intensity 9 or 10. Three were sensitive to cold and had stabbing pain, and one reported pulsatile pain. No patient presented nail alterations. There were no bone alterations on radiographic images and diagnostic suspicion of GT was supported by magnetic resonance images. Surgical treatment was indicated due to severe pain and functional limitation. The GT excision was performed by removing the nail through an L-shaped incision in the nail bed. After surgery, they all showed clinical improvement with return to previous activities and had no difficulty in wearing regular shoes. Three patients were pain-free and one had occasional stabbing pain of intensity 2. Half of them had nail changes. There has been no recurrence so far. Thus, we found that resection of subungual GT of the hallux was effective for the clinical improvement of patients.Level of Evidence: IV, case reports.

Treatment of Distal Tibiofibular Syndesmosis Injury Associated with Ankle Fractures with Suture Button.

Objective To evaluate the results obtained from the surgical treatment of malleolar ankle fractures associated with distal tibiofibular syndesmosis (DTFS) injury submitted to conventional surgical procedure for fracture fixation and DTFS fixation by suture button (SB). Methods Forty-nine patients were retrospectively evaluated, with a mean age of 45 years old and a mean follow-up of 34.1 months. Clinical and functional evaluation was based on the visual analogue scale (VAS) and on the American Foot and Ankle Society Score (AOFAS) for ankle and hindfoot, return to routine activities, and return to sport. Results The postoperative mean AOFAS and VAS were, respectively, 97.06 (confidence interval [CI 95%: 95.31-98.81] and 0.16 [CI 95% 0,04 - 0,29]. All patients returned to previous daily activities, and only 12 showed some residual symptom. There was no postoperative instability in any patient. Forty-six patients returned to sports activities and, of these, only 1 did not return to the level prior to the injury. Only two patients presented SB-related alterations. There was no report of dissatisfaction. Conclusion In malleolar fractures of the ankle with DTFS injury, the fixation of syndesmosis with SB demonstrated excellent postoperative results. Level of Evidence IV, retrospective case series.

Hand hygiene performance in an intensive care unit before and during the COVID-19 pandemic.

The current COVID-19 pandemic has heightened the focus on infection prevention in hospitals. We evaluated hand hygiene compliance with alcohol-based hand rub via electronic observation among healthcare workers in an intensive care unit from 2017 to 2020. The COVID-19 pandemic was not associated with an increase in hand hygiene compliance.

Comparing human to electronic observers to monitor hand hygiene compliance in an intensive care unit.

Objective: We sought to determine whether an electronic hand hygiene (HH) system could monitor HH compliance at similar rates to direct human observation. Methods: This 4-year proof-of-concept study was conducted in an intensive care unit (ICU) of a private tertiary-care hospital in São Paulo, Brazil, where electronic HH systems were installed in 2 rooms. HH compliance was reported respectively using direct observation and electronic counter devices with an infrared system for detecting HH opportunities. Results: In phase 1, HH compliance by human observers was 56.3% (564 of 1,001 opportunities), while HH compliance detected by the electronic observer was 51.0% (515 of 1,010 opportunities). In phase 2, human observers registered 484 HH opportunities with a HH compliance rate of 64.7% (313 of 484) versus 70.6% (346 of 490) simultaneously detected by the electronic system. In addition, an enhanced HH electronic system monitored activity 24 hours per day and HH compliance without the presence of a human observer was 40.3% (10,642 of 26,421 opportunities), providing evidence for the Hawthorne effect. Conclusions: The electronic HH monitoring system had good correlation with human HH observation, but compliance was remarkably lower when human observers were not present due to the Hawthorne effect (25%-30% absolute difference). Electronic monitoring systems can replace direct observation and can markedly reduce the Hawthorne effect.