Potential Roles of Inflammation on Post-Traumatic Osteoarthritis of the Ankle.

Post-traumatic osteoarthritis of the ankle (PTOA) is frequently observed following a debilitating consequence of intra-articular ankle fractures. Numerous risk factors contribute to the pathogenesis of PTOA, including articular incongruity, joint malalignment, and concomitant soft tissue damage. Despite attempts to restore joint anatomy and manage soft tissues to avoid long-term complications after intra-articular ankle fractures, the incidence of PTOA remains markedly elevated. Inflammatory processes triggered by intra-articular ankle fractures have emerged as potential instigators that expedite the progression of PTOA. Injury to the articular cartilage and subchondral bone may lead to the release of inflammatory mediators, which can contribute to cartilage degradation and bone resorption. This study provides a narrative review on the current knowledge concerning the association between inflammation and the development of PTOA following intra-articular ankle fractures. We also discuss novel therapeutic agents that target inflammatory pathways to impede the progression of post-traumatic osteoarthritis after intra-articular ankle fractures. These medication and interventions were summarized within this review article.

A windows technique for sustentaculum tali screw fixation using the sinus tarsi approach for calcaneal fractures: a cadaveric study.

INTRODUCTION: The minimally invasive approach for displaced intra-articular calcaneal fractures is significantly reducing postoperative wound complications. One minimally invasive method, the sinus tarsi approach (STA) has been increasingly widely used. STA is, however, challenging due to its technical demands and the risk of injury to the sural nerve (SN). The purpose of this study was to identify the SN and its branches including their anatomical relationship to the STA as well as to describe an anatomical windows technique for STA including determination of the safe angle for screw insertion into the sustentaculum tali fragment. METHODS: Thirty-two adult cadaveric legs were disarticulated at the knee and unpaired. STA was performed on each specimen. The anatomy and distribution of the sural nerve and its branches were identified in relation to the incision. Three surgical windows were identified and selected. Kirshner wires were inserted in pairs via each of the windows towards the center of the sustentaculum tali. The safe angle for wire insertion in relation to the SN or its branches was then measured as well as the appropriate intraoperative drilling angle. RESULTS: The plantar branch presented in the distal window in none of the samples, while the dorsal branches presented in 37.5% and the main SN presented in only 6.25%. In the middle window, the dorsal branch presented most often (43.75%) followed by the plantar branch (25.00%) and the SN (21.88%). In the proximal window, the SN presented in 100% of the samples, while the dorsal branch presented in none and the plantar branch presented in about 15.63% of the specimens. All three windows had their own acceptable average angle for screw insertion towards the sustentaculum tali. CONCLUSIONS: The distal window is the safest for surgical approach and for calcaneal surgery screw fixation in terms of avoiding sural nerve injury. In addition, that window provides a wide working angle for screw fixation.

Predicting Survival in Thai Patients After Low Impact Hip Fracture Using Flexible Parametric Modelling: A Retrospective Cohort Study.

Predictive post-hip fracture mortality models have been presented for specific time points (in-hospital, 30-days or 1-year) and most provide marginal predictions based on the patient's risk group. However, the predictive model for individual survival probability following hip fracture is not available. This study aimed to develop a flexible parametric model for predicting individual survival probability for hip fracture patients. In this retrospective study, the medical charts of 765 Thai patients admitted to hospital with a hip fracture resulting from low-impact injury from January 2014 to December 2018 were reviewed. Predictors for all-cause mortality were identified using flexible parametric survival analysis and were used to develop the predictive model. The model was calibrated using a calibration graph and discrimination performance was evaluated using the C-statistic. Internal validity was assessed using bootstrapping. The overall mortality rate of the hip fracture patients was 14%. Predictors significantly associated with survival after hip fracture were age, active malignancy, dementia or Alzheimer's disease, chronic obstructive pulmonary disorder, diabetes mellitus, hemoglobin concentration, eGFR<30 mL/min/1.73m2 and operative treatments. The model-predicted survival was similar to that actually observed in the very low survival group in the first year after hip fracture. In bootstrapping, the apparent C-statistic and the test C-statistic of the reduced model were 0.79 (95% CI 0.77-0.81) and 0.79 (95% CI 0.78-0.80), respectively. The flexible survival model provides good predictive power for individual survival probability at any given time point within the first year after hip fracture and would be an easy to use tool in clinical practice.

Comparison of three-dimensional and two-dimensional computed tomographies in the classification of acetabular fractures.

PURPOSE: This study compared the accuracy and timeliness of two-dimensional computed tomography (2DCT) and three-dimensional computed tomography (3DCT) in the diagnosis of different types of acetabular fractures and by different groups of interpreters using the Letournel and Judet classification system. METHODS: Twenty-five fractures cases, five each of five common types of acetabular fractures, were selected. Nineteen interpreters with different levels of experience (ten graduate trainees and nine radiologists) individually classified the fractures using multiplanar 2D and standardized 3DCT images. The 3DCT image set was comprised of 39 images of rotational views of the entire pelvis and the disarticulated fracture hip. Consensus reading by three experts served as a reference standard. RESULTS: Classification accuracy was 66% using 2DCT, increasing to 73% (p = 0.041) when 3DCT was used. Improvement occurred in the interpretation of transverse and posterior wall-type fractures (p < 0.01 and p = 0.015, respectively), but not in T-type, transverse with posterior wall, or both-column fractures. The improvement was noted only in the graduate trainee group (p = 0.016) but not the radiologist group (p = 0.619). Inter-observer reliability in the graduate trainee group improved from poor to moderate with 3DCT, but remained at a moderate level in both 2DCT and 3DCT in the radiologist group. The overall average interpretation time per case with correct diagnosis was 60 s for 2DCT but only 32 s for 3DCT. CONCLUSIONS: Standardized 3DCT provides greater reliability and faster diagnosis of acetabular fractures and helps improve the accuracy in transverse- and posterior wall-type fractures. In addition, it helps improve the accuracy of less experienced interpreters.

Prognostic Factors for All-Cause Mortality in Thai Patients with Fragility Fracture of Hip: Comorbidities and Laboratory Evaluations.

Background and Objectives: Although the types of comorbidities and laboratory evaluations are major factors associated with mortality after hip fractures, there have been no studies of the association of these factors and mortality in Thai hip-fracture patients. This study aimed to identify prognostic factors associated with mortality after a hip fracture in the Thai population, including types of comorbidities, treatment-related factors, and laboratory evaluations. Materials and Methods: This five-year retrospective study was conducted in a tertiary care hospital in Thailand. A total of 775 Thai patients who had been admitted with a hip fracture resulting from a simple fall were identified using the International Classification of Disease 10 codes, and a review of their medical charts was conducted. Associations between general factors, comorbidities, laboratory evaluations, treatment factors including type of treatment, and time to death were analyzed using the Cox proportional hazard regression and the hazard ratio (HR). Results: The overall mortality rate of hip fracture patients was 13.94%. Independent prognostic factors found to be significantly associated with mortality were nonoperative treatment (HR = 3.29, p < 0.001), admission glomerular filtration rate (GFR) < 30 mL/min/1.73 m2 (HR = 3.40, p < 0.001), admission hemoglobin concentration <10 g/dL. (HR = 2.31, p < 0.001), chronic obstructive pulmonary disorder (HR = 2.63, p < 0.001), dementia or Alzheimer's disease (HR = 4.06, p < 0.001), and active malignancy (HR = 6.80, p < 0.001). Conclusion: The types of comorbidities and laboratory evaluation findings associated with mortality in Thai patients with hip fractures include chronic obstructive pulmonary disorder, dementia or Alzheimer's disease, active malignancy, admission GFR < 30 mL/min/1.73 m2, and admission hemoglobin concentration <10 g/dL. The risks of mortality for Thai hip-fracture patients with these comorbidities or laboratory evaluation findings were 2.5, 4, 7, 3.5, and 2.5 times higher, respectively, than patients without those factors.

Negative pressure wound therapy for traumatic foot and ankle wound: two case reports and review of the literature.

This report describes treatment of patients who presented with open soft tissue injuries andAchilles tendon tears at the posterior ankle and heel from accidents. After appropriate debridement and/or Achilles tendon repair a large wound defect remained as well as a bare Achilles tendon. Negative pressure wound therapy was applied to the Achilles tendon to promote wound healing and healthy granulation. The size of wound decreased and the Achilles tendon was completely covered with granulation within two weeks. The remaining granulation tissue without tendon exposure was completely healed with secondary wound healing and/or skin grafting during the following two weeks after which motion of the ankle was satisfactory. Negative pressure wound therapy is an optional treatment for the complicated wounds where reconstructive surgery with a skin flap cannot be performed.

Second hip fractures at Chiang Mai University Hospital.

BACKGROUND: Hip fractures are a major public health problem. Patients who have suffered a hip fracture have an increased risk of a subsequent hip fracture. This study examines the incidence ofsecondhip fractures and attempts to identify underlying risk factors. OBJECTIVE: To examine the incidence ofsecond hip fractures in osteoporotic patients at Chiang Mai University Hospital and to identify risk factors related to second hip fractures. MATERIAL AND METHOD: A retrospective review was conducted of all low-energy mechanism hip fracture patients admitted during 2008 and 2009. Analysis of second hip fractures was conducted using survival analysis and logistic regression analysis. RESULTS: A total of 191 patients were observed for 391.68 person-years (mean 2.05 person-years per patient). Among that group, nine second hip fractures were identified, an overall incidence rate of 0.023 second fractures per person-year. Second hip fractures tended to occur within the first year following an initial hip fracture. There were no significant differences related to either gender or comorbid medical conditions. Logistic regression analysis revealed that increased risk of a second hip fracture was associated with age (highest between 80 to 89 years) and patients who were not treated for osteoporosis following their initial fracture. CONCLUSION: The incidence of second hip fractures at Chiang Mai University Hospital was 0.023 per person-year Careful follow-up of older patients, especially those over 80, and treatment ofosteoporosis with bisphosphonate plus vitamin D and calcium supplements was correlated with a reduction in the incidence of second hip fractures.

Correlation of proximal femoral bone geometry from plain radiographs and dual energy X-ray absorptiometry in elderly patients.

BACKGROUND: Fracture prevention in osteoporotic patients is the primary treatment goal in assessing bone mineral density, identification of fracture risk, and determination of who should be treated. The literature shows that parameters of proximal femoral bone geometry such as hip axis length, femoral neck shaft angle (FNA), femoral neck width (FNW) and femoral neck cortical thickness (FNCT) can predict the risk of hip fracture. Those parameters are presented automatically with dual energy X-ray absorptiometry (DXA) scans, which are available in well-equipped hospitals. OBJECTIVE: To determine the correlation between proximal femoral bone geometry and the parameters from DXA scans and those from plain radiographs. MATERIAL AND METHOD: Forty-eight patients with no previous hip fractures or history of secondary osteoporosis underwent both a DXA scan of the hip area and a plain hip radiograph done in the same position, 25 degrees internal rotation. Bone geometries from both groups were measured to determine the correlation using Pearson correlation coefficient. RESULTS: Correlation between the parameters HAL, FNA, FNW andFNCT from the DXA scans and from the measurement of the plain radiograph was significant (p < 0.01) and the level of correlation was moderate to high. The FNCT had least mean difference (0.04). In addition, the parameter FNCT less than 0.29 mm in both DXA scans and plain radiographs, showed a significant correlation with osteoporosis (T-score <-2.5). CONCLUSION: The bone geometry parameters from either DXA scans orplain radiographs may be used to predict osteoporotic hip fracture with a moderate to high correlation. Plain radiographs are very helpful when DXA scan results are not available. The FNCT parameter has a strong correlation with osteoporosis.

Foot and ankle problems in Muay Thai kickboxers.

BACKGROUND: Muay Thai kickboxing is a common sport that uses the foot and ankle in fighting. Muay Thai kickboxing trainees usually receive training in Thailand Foot and ankle problems in this group ofpeople who usually train barefoot remain unexplored OBJECTIVE: To evaluate the prevalence of common foot and ankle problems in Muay Thai kick boxers. MATERIAL AND METHOD: The present study is a cross-sectional survey of Muay Thai kick boxers practicing in northern Thailand. Interviews were conducted and foot and ankle examinations were evaluated Foot morphology was examined using a Harris mat footprint. RESULTS: One hundred and twenty-three Muay Thai kickbox ersinnine training gyms were included in this study. Common foot and ankle problems found in the Muay Thai kick boxers were callosity (59%), gastrocnemius contracture (57%), toe deformities (49.3%), wounds (10%) and heel pain (9%). Callosity was most commonly found on the forefoot (77.5%), on the plantar first metatarsal (55.3%) and on the big toe (33.3%). An association was found between a tight heel cord and a history of foot injury with prolonged periods of weekly training. Toe deformities such as hallux rigidus (37.6%) were also associated with prolonged periods of training (p = 0.001). No correlation was found between type of foot arch and foot and ankle problems. CONCLUSION: Plantar forefoot callosities and wounds as well as toe deformities including tight heel cords are some of the foot and ankle problems commonly found in Muay Thai kick boxers. They are associated with prolonged periods of barefoot training. The unique pattern of training and of the kicks in Muay Thai might be a path mechanism, leading to the development of foot and ankle problems.

Foot and ankle problems in Thai monks.

BACKGROUND: Foot and ankle problems in Thai monks have not been explored. This is an unshod population, and its members have a unique lifestyle living among others in our modern era. Beginning at their ordainment, they follow strict rules about barefoot walking, the amount of daily walking, and their sitting position, practices that theoretically can increase their risk of developing foot and ankle problems. OBJECTIVE: To evaluate the prevalence ofcommon foot and ankle problems in Thai monks. MATERIAL AND METHOD: A cross-sectional survey was conducted in combination with foot and ankle examinations of monks living in northern Thailand Foot morphology was examined using a Harris mat footprint. Results of the interviews and the foot and ankle examinations were evaluated. RESULTS: Two hundred and nine monks from 28 temples were included in this study. Common foot and ankle problems found included callosity (70.8%), toe deformities (18.2%), plantar fasciitis (13.4%), metatarsalgia (3.8%), and numbness (2.9%). Callosity and toe deformities were associated with prolonged barefoot walking over extended periods since ordainment (p < 0.05). The callosity was found on the forefoot (47.3%), lateral malleolus (40.7%), and heel (12%). Arch types were considered normal in 66.4% of cases, high in 21.6%, and low in 12%. No association was found between arch type and foot and ankle problems. CONCLUSION: Callosity and toe deformity were the most common foot and ankle problems found in Thai monks, especially those with prolonged period of barefoot walking and long-term duration ofordainment. The unique pattern of walking and sitting of Thai monks may have contributed to the development of those feet and ankle problems.

Off-loading total contact cast in combination with hydrogel and foam dressing for management of diabetic plantar ulcer of the foot.

BACKGROUND: The total contact cast is considered to be an effective method of off-loading a diabetic non-infected pressure ulcer. However complications have been reported in 1 to 15% of cases, e.g. prolonged healing of the ulcer. Debridement with modern dressings has been reported to be effective in promoting wound healing; however there have been few reported studies of the combination of modern dressings with the cast. OBJECTIVE: To evaluate the effectiveness of a combination of treatments on healing rates in diabetic non-infected plantar ulcer of the foot. MATERIAL AND METHOD: This retrospective study with prospective data collection was conducted between September 2010 and August 2012. Twenty diabetic patients with plantar neuropathic ulcer were treated using a combination of a contact cast plus hydrogel andfoam dressings. The size and location of the ulcer, ulcer healing, foot deformities and complications were evaluated. RESULTS: Of 21 ulcers, 20 (95.2%) healed completely in a mean time of 30.1 days (range 14 to 70 days). Healing times for forefoot and midfoot ulcers were 22.6 and 26.8 days, respectively, which is significantly shorter than the 51.7 days for heel ulcers. One patient who had an unhealed ulcer developed a severe infection two months after treatment, which necessitated below the knee amputation. There were three cases of recurrence of the ulcers after casting. CONCLUSION: Off-loading casting combined with modern dressings had a high rate of healing in short-term treatment of diabetic non-infected pressure ulcers. Recurrence of ulcers and new site abrasions were common complications; those complications may have been caused by association with bone deformity or improper footwear.

Vascular disruption of the talus: comparison of two approaches for triple arthrodesis.

BACKGROUND: For triple arthrodesis, a single medial incision has been proposed to avoid lateral wound complications and has demonstrated satisfactory fusion rates. This study aimed to compare the disruption to the arterial supply of the talus between the single-medial-incision approach and the 2-incision approach. METHODS: The 2 approaches for triple arthrodesis were compared by analyzing the disruption of arterial vasculature in 14 cadaveric specimens in randomized fashion. The arterial disruption was determined using CT angiography before and after surgery combined with analysis from dissection. The area of joint preparation from each technique was also analyzed and compared. RESULTS: The single-medial-incision approach caused a high incidence of damage to the deltoid artery (6 of 7 specimens, 86%) and the artery of the tarsal canal (7 of 7 specimens, 100%). The 2-incision approach resulted in damage to the artery of the tarsal sinus in all specimens (7 of 7 specimens, 100%), but the medial vasculature was spared given the limited dissection required to access the talonavicular joint. Through the single-medial-incision approach the percentage of debridement of the calcaneocuboid joint (36%) was significantly lower than the debridement using the 2-incision approach (85%, P < .01). There was no significant difference in joint preparation of the talonavicular and subtalar joints between the 2 approaches with the number of specimens available. CONCLUSION: From this cadaveric study, we found that both approaches could result in substantial disruption of the main blood supply to the talus. The single-medial-incision approach consistently disrupted the majority of blood supply to the talar body, while the 2-incision approach caused various degrees of vascular disruption to the talar head and neck. Using the single-medial-incision approach, the calcaneocuboid joint did not show adequate removal of articular cartilage due to difficulty accessing the joint surfaces. CLINICAL RELEVANCE: Vascular sparing to the talus should be considered when selecting an appropriate operative approach for triple arthrodesis. Although the clinical significance of this cadaveric study is limited, the 2-incision approach appeared to cause less vascular disruption to the talar body while allowing more complete joint preparation.

Varus external rotation stress test for radiographic detection of deep deltoid ligament disruption with and without syndesmotic disruption: a cadaveric study.

BACKGROUND: External rotation stress is used intraoperatively for diagnosing medial ankle and syndesmotic instability in rotational ankle fractures after reduction and fixation of the fibula. However, external rotation includes hindfoot, midfoot, and ankle motion. The purpose of this study was to determine the effect of hindfoot positioning when using the external rotation stress test. Isolated deep deltoid ligament (DDL) instability and combined DDL and syndesmotic instability were modeled. An intact fibula was used as a surrogate for an anatomically fixed fibula fracture. METHODS: Six cadaver specimens with full-length tib-fib articulations were used. Specimens were fixed into a Taylor Spatial Frame (Smith&Nephew, Memphis, TN) with 4 to 5 points of fixation in the tibia and the foot. Specimens were mounted in ankle and foot neutral position. Metal markers were placed at the medial gutter and syndesmosis. Anteroposterior (AP) and mortise radiographs were obtained in 3 positions: neutral hindfoot, valgus external rotation stress, and varus external rotation stress. For both valgus and varus external rotation stress, the frame was loosened and stressed to a hard end point and then locked. Three modes were studied: intact ligaments, DDL transected, and DDL+ syndesmosis transected. Digital radiographs were used to measure the displacement of the markers. RESULTS: The varus external rotation stress test demonstrated significant widening of the medial gutter in specimens with isolated DDL instability, in both AP (P = .01) and mortise (P = .02) views. Both maneuvers demonstrated significant medial gutter widening with combined DDL and syndesmosis disruption (P ≤ .01), although the varus external rotation stress test produced nearly twice as much displacement (10.7 vs 5.4 mm). Syndesmotic widening was not significant with either maneuver. CONCLUSIONS: Varus external rotation stress was more effective than valgus external rotation stress in demonstrating displacement of markers at the medial gutter and on AP and mortise radiographs for both DDL and DDL with syndesmotic instability. CLINICAL RELEVANCE: These findings may lead to improved clinical detection of rotational ankle instability from combined DDL and syndesmotic disruption, which may affect decision making for using syndesmotic fixation when using intraoperative stress fluoroscopy images. Occult DDL instability may be underdiagnosed, and this may affect future directions of the treatment of rotational ankle fractures and severe sprains.

Minimally invasive plate osteosynthesis of distal tibial fracture using a posterolateral approach: a cadaveric study and preliminary report.

PURPOSE: The aims of this anatomical study were to evaluate the feasibility of minimally invasive plate osteosynthesis (MIPO) using a posterolateral approach in distal tibial fractures and to study the relationship between neurovascular structures and the plate. METHODS: Two separate incisions, one proximal and one distal, were made on the posterolateral aspect of ten cadaveric legs in the prone position. A 14-hole contralateral anterolateral distal tibial locking plate was inserted into the submuscular tunnel using a posterolateral approach, and one screw was fixed on each side of the proximal and distal tibia. The MIPO tunnel was then explored to identify the relationship between neurovascular bundles and plate. RESULTS: For the proximal incision, retraction of the flexor hallucis longus and the tibialis posterior muscles medially was very important because it could protect the posterior tibial artery and the tibial nerve during plating. The sural nerve and lesser saphenous vein were easily identified and retracted in the superficial layer of the distal incision. In addition, we achieved satisfactory outcomes after using this MIPO technique in one patient. CONCLUSION: Based on the results of our study, it seems that using the MIPO technique through a posterolateral approach should be a reasonable and safe treatment option for distal tibial fractures, especially when the anterior soft tissue is compromised. However, studies with a higher level of evidence should be done in more patients to confirm the clinical safety of using this technique.

The Specific Anatomical Morphology of Lateral Ankle Ligament: Qualitative and Quantitative Cadaveric based Study.

OBJECTIVE: The accurate understanding in morphological features of the lateral ankle ligaments is necessary for the diagnosis and management of ankle instability and other ankle problems. The purpose of this study was to evaluate the anatomical morphology and the attachment areas of lateral ligament complex of ankle joint based on the cadaveric study. METHODS: Fifty-four fresh frozen cadaveric ankles were dissected to evaluate the lateral ankle ligaments. Each ligament was separated into two or three small bundles. In the investigated footprint areas, acrylic colors were used as a marker point to locate specific areas of ligament bundle attached to the bone. The Image J software was used to measure and analyze the sizes of the specific footprint areas to achieve descriptive statistical analysis. RESULTS: The double bands of anterior talofibular ligament (ATFL) were found as a major type in the present study with 57.41% (31 of 54 ankles) while the single band of ATFL was observed in 42.59% (23 of 54 ankles). The attachment sizes of the ATFL, posterior talofibular ligament (PTFL) and calcaneofibular ligament (CFL) were evaluated into two areas; proximal and distal attachments. The average of proximal or fibular part of ATFL, PTFL and CFL were 85.06, 134.27, 93.91 mm2 respectively. The average of distal part of ATFL, PTFL and CFL were 100.07, 277.61, 249.39 mm2 respectively. CONCLUSION: Considering the lateral ankle ligament repaired or reconstruction especially using arthroscopy, the precise understanding in specific detail of the lateral ankle ligament may help both diagnose and select the appropriate treatment for solving the ankle problems. These observations may help the surgeon to perform the surgical procedure for determining the appropriate techniques and avoid complication to patients.

Preoperative Correction of Low Hemoglobin Levels Can Reduce 1-Year All-Cause Mortality in Osteoporotic Hip Fracture Patients: A Retrospective Observational Study.

PURPOSE: Osteoporotic hip fracture surgery is associated with a risk of morbidity and mortality. Admission hemoglobin levels <10 g/dL have been documented as a strong predictor of mortality risk. This study aimed to investigate the mortality outcome between osteoporotic hip fracture patients who had preoperative hemoglobin levels raised to ≥10 g/dL and those with hemoglobin levels were <10 g/dL. PATIENTS AND METHODS: This 5-year retrospective observational study included 226 participants with osteoporotic hip fractures that required surgery and who had admission hemoglobin levels <10 g/dL. Patients were categorized into two groups: those with corrected preoperative hemoglobin ≥10 g/dL and those with either corrected or uncorrected preoperative hemoglobin <10 g/dL. Outcomes were analyzed using Cox proportional hazard regression adjusted for confounders. Results are presented as hazard ratio (HR) and 95% confidence interval (95% CI). RESULTS: Among 226 the patients, the overall mortality rate was 17.25% (n=39/226) of the 226 patients, 93 (41.15%) had their hemoglobin levels raised to ≥10 g/dL by red blood cell transfusion. Multivariable analysis after adjustment for confounders showed a 50% lower incidence of mortality among patients with preoperative hemoglobin levels ≥10 g/dL than among those with hemoglobin levels <10 g/dL (HR 0.50, 95% CI (0.25-0.99), p=0.048). CONCLUSION: In osteoporotic hip fracture patients with admission hemoglobin <10g/dL, raising preoperative hemoglobin levels to ≥10 g/dL can significantly reduce the risk of mortality. Testing for and correction of low preoperative hemoglobin levels is of value in hip surgery patients.

Preventing damage to arthroscopic lens during surgery.

PURPOSE: To evaluate the relation between the relative diameter of instrument tips and the distance between the arthroscopic lens and the tips of the instruments in terms of preventing lens damage during arthroscopy. METHODS: By use of a custom-designed station device with 2 perpendicular portals, images of multiple-sized shaver tips (2.5, 3.5, 4.0, 5.0, and 5.5 mm) were obtained from 4 different arthroscopes (4 mm 30°, 4 mm 70°, 2.7 mm 30°, and 2.7 mm 70°) at varying distances of 0 to 10 mm at 1-mm increments. The relative diameter of the visualized instrument tips and the distance between the arthroscopic lens and the tips of the instruments were evaluated. RESULTS: The relative diameter of the shaver tips measured by 2 investigators showed excellent intraobserver and interobserver reliability. By use of 2 mm as the safe distance from the arthroscopic lens to the tip of the shaver, 13 of 14 arthroscopic lens-shaver combinations were considered safe when the visualized shaver tip was smaller than one-half of the arthroscopic visual field. Six of 14 combinations were considered unsafe when the visualized shaver tip was larger than three-fourths of the visual field. CONCLUSIONS: In this experimental study, the safe distance of 2 mm could be maintained when arthroscopic instruments used during surgery (e.g., shavers and burrs) were observed to be less than one-half of the arthroscopic visual field. The relative diameter of the visualized instrument tip was a reliable guide to prevent arthroscopic lens damage. CLINICAL RELEVANCE: To avoid damaging the arthroscope lens during surgery, arthroscopists can maintain a safe distance by keeping the relative diameter of the instrument tip (e.g., arthroscopic burr) to less than one-half of the arthroscopic visual field.

Effect of Bone Resection on Posterior Talofibular Ligament Integrity for Posterior Ankle Impingement Syndrome: A Cadaveric Study.

PURPOSE: The purpose of this study was to evaluate the attachment areas of the posterior talofibular ligament (PTFL) on the posterolateral tubercle of the talus and the remaining PTFL attachment areas after consequential bony excision. METHODS: Thirty fresh cadaveric ankles were dissected to study the proximal and distal attachment of the PTFL and separated the PTFL into anterior and posterior bundles. The description of the PTFL footprint and the anatomic landmarks from the surrounding structures were analyzed during consequential posterolateral bony excision. RESULTS: The average PTFL dimension was 26.11 mm (length), 7.65 mm (width), and 1.82 mm (thickness). The footprint area of the PTFL on the talar site consists of the posterior bundle (76.82%) and the anterior bundle (23.18%). If posterolateral tubercle excision was stayed up to a line of a bottom of the flexor hallucis longus (FHL) groove, at least 89% of the PTFL can be preserved. CONCLUSION: The posterior bundle of the PTFL is the main bundle on the talar footprint area. To maintain the majority of the attachment of the PTFL, the resection of the posterolateral process could be performed to the bottom of the FHL tendon groove. If resection reaches to the posterior articular cartilage, less than 50% of the PTFL will be preserved. Understanding the footprint of the PTFL plays a key role in posterior ankle impingement surgery. CLINICAL RELEVANCE: This study provides guidance for resection of the posterolateral tubercle of the talus and a portion of the PTFL attachment for posterior ankle impingement syndrome. Too much resection of the tubercle may cause instability symptoms.

Long-term mortality after osteoporotic hip fracture in Chiang Mai, Thailand.

The purpose of the study was to investigate 10-yr mortality and associated factors after osteoporotic hip fracture. A prospective cohort study of mortality and associated factors was carried out in patients who sustained hip fracture and were admitted to Chiang Mai University Hospital from 1998 through 2003. Eligibility criteria were defined as age over 50yr, hip fracture caused by simple fall, and Singh index of 3 or less.Mortality rates at 3, 6, 12, 24, 36, 60, 96, and 120mo were 10%, 14%, 18%, 27%, 32%, 45%, 55%, and 68%, respectively. One-year mortality rates were 31% in males and 16% in females. The median survival time was 6yr. Ten-year mortality was 68%. Factors correlated with higher mortality were male gender, age greater than 70yr, and nonoperative treatment. Mortality after osteoporotic hip fracture in Thais was extremely high, especially in the first year. It was about 8 times higher than that in the age-adjusted general population.

Arthroscopic debridement for first metatarsophalangeal joint arthrodesis with a 2- versus 3-portal technique: a cadaveric study.

PURPOSE: To evaluate the safety and efficacy of arthroscopic debridement for arthrodesis of the first metatarsophalangeal (MTP) joint using a 2-portal technique versus a 3-portal technique. METHODS: Twelve cadavers, with a mean age of 60 years, were subjected to arthroscopic debridement of the first MTP joint. Dorsolateral and dorsomedial portals were used in 6 specimens, whereas a medial portal was added in the other 6 specimens. The articular cartilage was debrided on both the proximal and distal surfaces and stabilized with a K-wire. The surrounding neurovascular structures were evaluated for injuries and measured for the distance from the portals. The fusion contact areas were estimated and denuded surfaces were measured on both sides. Results between the 2- and 3-portal techniques were compared. Statistical significance was taken as P < .05. RESULTS: The mean estimated fusion contact area was 180.19 mm(2) on the proximal phalanx and 180.21 mm(2) on the distal metatarsal articular surfaces. On the proximal phalanx, the percentage of denuded area was 94.71% with the 2-portal technique and 97.60% with the 3-portal technique. On the distal metatarsal, the percentage of denuded area was 93.31% with the 2-portal technique and 95.22% with the 3-portal technique. The 3-portal technique statistically increased the area of debridement on the plantar-medial surface of the distal metatarsal. The mean distance from the dorsolateral portal to the dorsolateral hallucal nerve was 3.4 mm. The mean distance from the dorsomedial portal to the dorsomedial hallucal nerve was 4 mm. The medial portal was, on average, 10.5 mm from the dorsomedial hallucal nerve and 13 mm from the plantar-medial hallucal nerve. There was no visible nerve injury detected. CONCLUSIONS: The 3-portal technique for arthroscopic-assisted arthrodesis of the first MTP joint allowed more complete cartilage debridement when compared with the 2-portal technique. The additional medial portal was found to be safe from the surrounding neurovascular structures. CLINICAL RELEVANCE: Joint preparation for arthroscopic assisted arthrodesis of the first MTP joint can be safely and effectively performed using 3-portal technique, which may reduce the risk of non-union.