Primary Deltoid Repair for Ankle Fracture Using All-Suture Anchors.

Primary repair of the deltoid ligament is a common surgical option for unstable ankle fracture. However, controversy exists regarding whether such repair is necessary or provides any benefit to patient outcomes. A retrospective study was performed following acute deltoid repairs using all-suture bone anchors. Patients at 2 surgical centers were included when they were over 18 years old at surgery, had a medial clear space (MCS) greater than 4 mm preoperatively, and had at least 6 months of follow-up. Subjective outcomes were measured with PROMIS, FAAM, and numeric rating scale. Preoperative and follow-up scores were compared with t tests (p < .05). For the 47 patients identified, age at time of surgery was 30.6 ± 14.9 years (range 15.4-65.0 years). Follow-up data were captured for 36 (73%) of the patients at 75 ± 37 weeks (range 18-169 weeks) after surgery. Mean time to weightbearing was 4 ± 1 weeks (range 1-7 weeks). Patients returned to sport 14 ± 5 weeks after surgery (range 8-41 weeks). Various complications consisted of wound infection, superficial dehiscence, and complex regional pain syndrome (CRPS). The PROMIS, FAAM, and NRS patient outcome scores improved significantly from preoperative to postoperative follow-up. Significant reduction in the radiographic MCS postoperatively occurred in all patients. These findings suggest primary deltoid repair when associated with ankle fracture to be a safe procedure and has the potential of allowing early weightbearing and return to sports.

Are Prospective Criteria or Objective Clinical Measures Utilized in Return to Play (RTP) Decision Making After Ankle Surgery? A Scoping Review.

Background: Manuscripts discussing return to play (RTP) following ankle surgery are common. However, the definition for RTP and the method by which it is determined remains unclear. The purpose of this scoping review was to clarify how RTP is defined following ankle surgery in physically active patients, to identify key factors informing RTP decision making (such as objective clinical measures), and make recommendations for future research. Methods: A scoping literature review was performed in April 2021 using PubMed, EMBASE, and Nursing and Allied Health databases. Thirty studies met inclusion criteria: original research following ankle surgery reporting at least 1 objective clinical test and documentation of RTP. Data were extracted for study methods and outcomes (RTP definition, RTP outcomes, and objective clinical tests). Results: The scoping review found studies on 5 ankle pathologies: Achilles tendon rupture, chronic lateral ankle instability, anterior ankle impingement, peroneal tendon dislocation, and ankle fracture. RTP criteria were not provided in the majority of studies (18/30 studies). In the studies that provided them, the RTP criteria were primarily based on time postsurgery (8/12) rather than validated criteria. Objective clinical outcome measures and patient-reported outcome measures (PROMs) were documented for each surgery when available. Both clinical outcomes and PROMs were typically measured >1 year postsurgery. Conclusion: In physically active patients who have had ankle surgery, RTP remains largely undefined and is not consistently based on prospective objective criteria nor PROMS. We recommend standardization of RTP terminology, adoption of prospective criteria for both clinical measures and PROMs to guide RTP decision making, and enhanced reporting of patient data at the time of RTP to develop normative values and determine when the decision to RTP is not safe. Level of Evidence: Level IV, scoping review.

Assessment and Treatment of Sports Injuries to the First Metatarsophalangeal Joint.

Turf toe injuries have been increasing in numbers in recent years. Injury to the plantar restraints of the first metatarsophalangeal joint can lead to significant disability in athletes, affecting their push-off and ability to perform on the athletic field. Most turf toe injuries can be treated conservatively with rest, ice, compression, immobilization if needed, and a dedicated rehabilitation program; however, in some injuries, the plantar restraints are torn and the joint becomes unstable. If necessary, turf toe injury and its many variants can be surgically repaired with the expectation that the athlete will be able to return to play.

Dehydrated Amnion/Chorion Improves Achilles Tendon Repair in a Diabetic Animal Model.

INTRODUCTION: Healing of tendon injuries is often plagued by significant scar formation and compromised biomechanical function. For those with diabetes, these injuries are further complicated by alterations to the extracellular matrix of the tendon, poor circulation, and delayed wound healing; consequently, complications and re-rupture rates for patients with diabetes are reported higher than the typical patient population. Placental derived membranes, specifically dehydrated human amnion/chorion membranes (dACMs), have been utilized clinically as an adhesion barrier, and these membranes have been shown to reduce scarring and aid in tissue repair. OBJECTIVE: The purpose of this study was to evaluate the effect of dACMs on tendon repair in a diabetic model with impaired healing. MATERIALS AND METHODS: Using a type II diabetic model (BBZDR/WOR rats), a full-thickness injury was made through the Achilles tendon and repaired using a modified Kessler method. Repaired tendons were wrapped with dACM or left unwrapped as a control (n = 15/group; n = 30 total). Tendons were retrieved at 14 (n = 5/group; n = 10 total) or 28 days (n = 10/group; n = 20 total) and evaluated using histology, immunofluorescence, and biomechanical testing. RESULTS: Treatment of tendons with dACM resulted in reduced failure rates, increased cell migration, and improved mechanical properties (compared with unwrapped controls). The dACM-treated tendons also showed changes in the production of several important biomarkers to tendon healing at both 14 and 28 days; most notably, Scleraxis was found to be upregulated in dACM-treated tendons. CONCLUSIONS: This study highlights a promising treatment option for this challenging clinical population.

Biomechanical Comparison of 3 Syndesmosis Repair Techniques With Suture Button Implants.

BACKGROUND: Suture button fixation of syndesmotic injury is growing in popularity, as it has been shown to provide adequate stability in a more cost-effective manner than screw fixation while allowing more physiologic distal tibiofibular joint motion. However, the optimal repair technique and implant orientation have yet to be determined. PURPOSE/HYPOTHESIS: The purpose of this study was to biomechanically compare 3 suture button construct configurations/orientations for syndesmosis fixation: single, parallel, and divergent. The authors hypothesized that all 3 methods would provide adequate stabilization but that the divergent technique would be the most stable. STUDY DESIGN: Controlled laboratory study. METHODS: The fixation strengths of 3 stabilization techniques with suture button devices were compared with 10 cadaveric legs each (N = 30). Ankle motion under cyclic loading was measured in multiple planes: first in the intact state, then following simulated syndesmosis injury, and then following fixation with 1 of 3 randomly assigned constructs-1 suture button, 2 suture buttons in parallel, and 2 divergent suture buttons. Finally, axial loading with external rotation was applied to failure. RESULTS: All syndesmotic fixation methods provided stability to the torn state. There was no statistically significant difference among the 3 fixation techniques in biomechanical stability. Failure most commonly occurred through fibular fracture at supraphysiologic loads. CONCLUSION: Suture button implant fixation for syndesmotic injury appears to provide stability to the torn syndesmosis, and the configuration of the fixation does not appear to affect the strength or security of the stabilization. CLINICAL RELEVANCE: This study provides further insight into the biomechanics and optimal configuration of suture button fixation of the torn syndesmosis. Based on these results, the addition of a second suture button may not significantly contribute to immediate postoperative stability.

Operative Outcomes of Grade 3 Turf Toe Injuries in Competitive Football Players.

BACKGROUND: Turf toe is a term used to describe a hyperextension injury to the first metatarsophalangeal joint. Although the vast majority of turf toe injuries can be treated successfully without operative intervention, there are instances where surgery is required to allow the athlete to return to play. Although there is a plethora of literature on turf toe injuries and nonoperative management, there are currently few reports on operative outcomes in athletes. METHODS: We obtained all cases of turf toe repair according to the ICD-10 procedural code. The inclusion criteria included: age greater than 16, turf toe injury requiring operative management and at least a varsity level high school football player. The charts were reviewed for age, BMI, level of competition, injury mechanism, football position, setting of injury and playing surface. In addition, we recorded the specifics of the operative procedure, a listing of all injured structures, the implants used and the great toe range of motion at final follow-up visit. The AOFAS Hallux score and VAS was used postoperatively as our outcome measures. Our patient population included 15 patients. The average follow-up time was 27.5 months. RESULTS: The average patient was 19.3 years old with a body mass index of 32.3. The average playing time missed was 16.5 weeks. The average dorsiflexion range of motion at the final follow-up was 42.3 degrees. At final follow-up, the average AOFAS Hallux score was 91.3. The average VAS pain score was 0.7 at rest and 0.8 with physical activity. CONCLUSION: Complete turf toe injuries are often debilitating and may require operative management to restore a pain-free, stable, and functional forefoot. This study represents the largest cohort of operatively treated grade 3 turf toe injuries in the literature and demonstrates that good clinical outcomes were achieved with operative repair. LEVEL OF EVIDENCE: Level IV, case series.

Tibial Stress Fracture Secondary to Half-Pins in Circular Ring External Fixation for Charcot Foot.

BACKGROUND: There is an increasing trend for surgical correction of the deformity associated with Charcot neuroarthropathy of the foot and ankle (Charcot foot) in order to allow ambulation with commercially available therapeutic footwear. The significant rate of surgical and medical morbidity associated with extensive conventional operative correction has led many surgeons to use limited surgical dissection and stabilization with circular ring external fixation. METHODS: A retrospective chart review was performed on 254 patients at 2 academic medical centers who underwent surgical correction for diabetes-associated Charcot foot deformity with limited soft tissue dissection and stabilization accomplished with a statically applied circular external fixator. Tibial stress fractures developed in 10 of the patients. RESULTS: Seven of the fractures developed in the 42 patients in whom tibial block fixation was accomplished with half-pins (16.7%), and 3 fractures developed in the 202 patients in whom tibial block fixation was accomplished with tensioned fine wires (1.5%). Three of the tibial stress fractures were successfully treated with extension of the circular frame above the level of the stress fracture. Four fractures were successfully treated with closed intramedullary nailing and 3 with weight-bearing total contact casts. Two tibial fractures occurred through pin sites (all half-pins) in 120 nonneuropathic patients who underwent application of circular ring external fixators during the same 6-year period. CONCLUSION: Tibial stress fracture is an unusual complication associated with the use of circular ring external fixation. This investigation highlights the significantly greater risk for the development of this complication in diabetic patients undergoing surgical correction for Charcot foot deformity when half-pins are used for tibial block stabilization, compared with tensioned fine wires. We now recommend the universal use of tensioned fine wires for tibial block fixation when circular ring fixation is performed in patients with Charcot foot arthropathy. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Radiographic evaluation of plantar plate injury: an in vitro biomechanical study.

BACKGROUND: The term turf toe has been generally applied to athletic dorsiflexion injuries of the hallux metatarsophalangeal (MTP) joint. Variations in injury patterns coupled with the complexity of the MTP joint makes the diagnosis of more severe injuries challenging and may lead to a failure in recognition of an unstable joint and a subsequently prolonged recovery. Although the proximal migration of one or both sesamoids has been previously identified with a plantar plate disruption, the current study proposes a quantitative grading system based on dorsiflexion stress radiographs, providing a predictable and reproducible test for evaluating the extent of injury to the first MTP joint. METHODS: Twenty-four nonpaired fresh-frozen foot/ankle specimens with no history or physical evidence of prior injury were used in this study. The specimens were randomly assigned into 4 cutting groups, and the 4 main distal ligaments of the plantar plate were identified and sectioned. Lateral dorsiflexion fluoroscopic stress images were obtained in the intact state and with each subsequent cut. With each image, measurements from the distal margin of the sesamoids to the most proximal margin of the proximal phalanx were taken. Images were obtained at 45 degrees with both a fibrous loop wrapped around the interphalangeal joint and applying 15 N and also with a manual dorsiflexion stress. Statistical testing performed was a repeated-measures analysis of variance with Tukey post hoc to compare measurements between each group to determine if movement of the sesamoid bones relative to the phalanx quantitatively increased with each structure that was cut. RESULTS: Our results demonstrate a relationship between the number of ligaments injured in the turf toe simulation and an increase in sesamoid phalangeal distance. We found that an increase of 3 mm in the distance from the sesamoids to the proximal phalanx was significant and predictive of a severe injury to the plantar plate. CONCLUSION: Injuries producing differences of 3 mm or greater from the intact state have a high likelihood of having sustained injury to at least 3 of the 4 ligaments of the plantar plate complex. This study is the first to establish a quantitative grading scale for evaluating turf toe injuries radiographically based on changes in movement of the sesamoids relative to the intact state. CLINICAL RELEVANCE: In assessing a turf toe injury, historically the evaluation has been qualitative, but our study provides quantifiable data for evaluation of the severity of plantar plate injuries, which may provide guidance to physicians for treatment decisions.

Anatomic suture anchor versus the Broström technique for anterior talofibular ligament repair: a biomechanical comparison.

BACKGROUND: Despite the popularity of the Broström procedure for secondary repair of chronic lateral ankle instability, there have been no biomechanical studies reporting on the strength of this secondary repair method, whether using suture fixation or suture anchors. HYPOTHESIS: The purpose of our study was to perform a biomechanical comparison of the ultimate load to failure and stiffness of the traditional Broström technique using only a suture repair compared with a suture anchor repair of the anterior talofibular ligament (ATFL) at time zero. We believed that fixation strength of the suture anchor repair would be closer to the strength of the native ligament and allow more aggressive rehabilitation. STUDY DESIGN: Controlled laboratory study. METHODS: Twenty-four fresh-frozen cadaveric ankles were randomly divided into 4 groups of 6 specimens. One group was an intact control group, and the other groups consisted of the traditional Broström and 2 suture anchor modifications (suture anchors in talus or fibula) of the Broström procedure. The specimens were loaded to failure to determine the strength and stiffness of each construct. RESULTS: In load-to-failure testing, ultimate failure loads of the Broström (68.2 ± 27.8 N; P = .013), suture anchor fibula (79.2 ± 34.3 N; P = .037), and suture anchor talus (75.3 ± 45.6 N; P = .027) repairs were significantly lower than that of the intact (160.9 ± 72.2 N) ATFL group. Stiffness of the Broström (6.0 ± 2.5 N/mm; P = .02), suture anchor fibula (6.8 N/mm ± 2.7; P = .05), and suture anchor talus (6.6 N/mm ± 4.0; P = .04) repairs were significantly lower than that of the intact (12.4 N/mm ± 4.1 N/mm) ATFL group. The 3 repair groups were not significantly different from each other, but all 3 were substantially lower in strength and stiffness when compared to the intact ATFL. CONCLUSION: The use of suture anchors to repair the ATFL produces a repair that can withstand loads to failure similar to the suture-only Broström repair. However, all 3 repair groups were much weaker than the intact, uninjured ATFL. CLINICAL RELEVANCE: Biomechanically, the results show that both suture anchor and direct suture repair of the ATFL provide similar strength and stiffness. Unfortunately, these methods provide less than half the strength and stiffness of the native ATFL at time zero. As a result, regardless of the repair method, it is necessary to sufficiently protect the repair to avoid premature failure.

Skeletal traction versus external fixation in the initial temporization of femoral shaft fractures in severely injured patients.

BACKGROUND: : Damage control with external fixation (DC-EF) of femoral shaft fractures in polytrauma patients is becoming standard treatment in many trauma centers. However, skeletal traction (ST) has long been used in the temporization of fractures. The purpose of this study was to compare the major physiologic clinical outcomes of provisional ST with DC-EF of femoral shaft fractures in severely injured patients. METHODS: : We retrospectively reviewed 205 patients sustaining blunt trauma, a femoral shaft fracture, and an Injury Severity Score > or =17 from 2001 to 2007 at a level I trauma center. Patients underwent definitive fixation in the first 24 hours with intramedullary nailing (IMN) (N = 126), initial DC-EF with delayed definitive treatment (N = 19), or initial ST with delayed definitive treatment (N = 60). Incidences of adult respiratory distress syndrome, multiple organ failure, sepsis, pneumonia, pulmonary embolism, and deep vein thrombosis were evaluated. Length of stay (LOS), intensive care unit LOS, days of mechanical ventilation, and mortality were also compared. RESULTS: : There were no significant differences between ST and DC-EF groups in age, mechanism of injury, Injury Severity Score, Glasgow Coma Scale score on arrival, mean time to definitive fixation (4.1 days versus 5.0 days, respectively), or Abbreviated Injury Scale for chest. However, the ST group had a higher Abbreviated Injury Scale-head (2.5 versus 1.0, p = 0.0026). There were no significant differences in subsequent rates of adult respiratory distress syndrome, multiple organ failure, pulmonary embolism, deep vein thrombosis, pneumonia, mechanical ventilation days, intensive care unit LOS, and death. However, the ST group had a lower rate of sepsis (8.3% versus 31.6%, p = 0.0194) and a shorter LOS (26.5 days versus 36.2 days, p = 0.0237) than the EF group. CONCLUSION: : DC-EF of femur fractures in severely injured patients offers no significant advantage in clinical outcomes compared with ST. Unless initially subjected to general anesthesia for life saving procedures, the use of ST as a temporization method remains a practical option.