Tenosynovial Giant Cell Tumor in the Midfoot Treated With Femoral Head Allograft Reconstruction.

Tenosynovial giant cell tumor (also known as giant cell tumor of tendon sheath or pigmented villonodular synovitis) is a rare soft tissue tumor that arises from the tenosynovium of a tendon sheath or the synovium of a diarthrodial joint. This disease process occurs infrequently in the foot and ankle but can result in significant bone erosion and destructive changes of affected joints. These cases are challenging to treat, because the tumor most commonly presents in young, active patients and can be associated with extensive bone loss. We review a case of tenosynovial giant cell tumor of tendon sheath of the midfoot, which was treated with mass resection, structural femoral head allograft bone grafting, and internal fixation with dorsal plating. The patient had achieved successful bony fusion and acceptable functional outcomes at the final follow-up visit 40 months postoperatively.

A biomechanical comparison study of a modern fibular nail and distal fibular locking plate in AO/OTA 44C2 ankle fractures.

BACKGROUND: A lateral approach with open reduction and internal fixation with a plate is a very effective technique for the majority of distal fibular fractures. However, this open approach for ankle fixation may be complicated by wound dehiscence and infection, especially in high-risk patients. An alternative to plating is an intramedullary implant, which allows maintenance of length, alignment, and rotation and which allows for decreased soft tissue dissection. While there has been clinical data suggesting favorable short-term outcomes with these implants, there is no current biomechanical literature investigating this technology in this particular fracture pattern. This study sought to biomechanically compare an emerging technology with an established method of fixation for distal fibular fractures that traditionally require an extensive exposure. METHODS: Ten matched cadaveric pairs from the proximal tibia to the foot were prepared to simulate an Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) 44C2 ankle fracture and randomized to fixation with a distal fibular locking plate or intramedullary fibular rod. A constant 700-N axial load was applied, and all specimens underwent testing for external rotation stiffness, external rotation cyclic loading, and torque to failure. The syndesmotic diastasis, stiffness, torque to failure, angle at failure, and mode of failure were obtained from each specimen. RESULTS: There was no significant difference in syndesmotic diastasis during cyclic loading or at maximal external rotation between the rod and plate groups. Post-cycle external rotation stiffness across the syndesmosis was significantly higher for the locking plate than the fibular rod. There was no significant difference between the rod and plate in torque at failure or external rotation angle. The majority of specimens had failure at the syndesmotic screw. CONCLUSIONS: In the present cadaveric study of an AO/OTA 44C2 ankle fracture, a modern fibular rod demonstrated less external rotation stiffness while maintaining the syndesmotic diastasis to within acceptable tolerances and having similar failure characteristics.

Comparison of modern locked plating and antiglide plating for fixation of osteoporotic distal fibular fractures.

BACKGROUND: Fractures in osteoporotic patients can be difficult to treat because of poor bone quality and inability to gain screw purchase. The purpose of this study is to compare modern lateral periarticular distal fibula locked plating to antiglide plating in the setting of an osteoporotic, unstable distal fibula fracture. METHODS: AO/OTA 44-B2 distal fibula fractures were created in sixteen paired fresh frozen cadaveric ankles and fixed with a lateral locking plate and an independent lag screw or an antiglide plate with a lag screw through the plate. The specimens underwent stiffness, cyclic loading, and load to failure testing. The energy absorbed until failure, torque to failure, construct stiffness, angle at failure, and energy at failure was recorded. RESULTS: The lateral locking construct had a higher torque to failure (p=0.02) and construct stiffness (p=0.04). The locking construct showed a trend toward increased angle at failure, but did not reach statistical significance (p=0.07). Seven of the eight lateral locking plate specimens failed through the distal locking screws, while the antiglide plating construct failed with pullout of the distal screws and displacement of the fracture in six of the eight specimens. CONCLUSION: In our study, the newly designed distal fibula periarticular locking plate with increased distal fixation is biomechanically stronger than a non-locking one third tubular plate applied in antiglide fashion for the treatment of AO/OTA 44-B2 osteoporotic distal fibula fractures. LEVEL OF EVIDENCE: V: This is an ex-vivo study performed on cadavers and is not a study performed on live patients. Therefore, this is considered Level V evidence.

Acute and Chronic Injuries to the Syndesmosis.

Syndesmotic injuries may occur as an isolated ligamentous disruption or with associated malleolar fractures. It is imperative these injuries be identified and managed properly to prevent any long-term dysfunction and morbidity. There are multiple surgical interventions that can be used for the treatment of acute and chronic syndesmotic injuries. Obtaining and maintaining an anatomic reduction is the key to long-term success when treating syndesmotic injuries.

A comparison of 30-day complications following plate fixation versus intramedullary nailing of closed extra-articular tibia fractures.

BACKGROUND AND PURPOSE: Tibial shaft fractures are often treated by intramedullary nailing (IMN) or plate fixation. Our purpose was to compare the 30-day complication rates between IMN and plate fixation of extra-articular tibial fractures. MATERIALS AND METHODS: We conducted a retrospective analysis of prospectively collected patient demographics, comorbidities, and 30 day complications of isolated closed extra-articular tibial shaft fractures from 2006 to 2012 using the American College of Surgeon's National Surgical Quality Improvement Program (ACS-NSQIP) database. A 1:2 propensity-matched dataset was created to control for differences in preoperative demographics and comorbidities across the plate fixation and IMN groups. Univariate and multivariate analyses were used to assess differences in complications between the groups and the independent effects of plate fixation or IMN on complications. RESULTS: A total of 771 patients were identified with 234 (30.4%) in the plate fixation and 537 (69.6%) in the IMN group. We found no statistical difference in rates of wound complications, medical complications, reoperation, or mortality in our propensity matched analyses. Plate fixation was found to be independently associated with a lower risk of postoperative blood transfusion compared to IMN (odds ratio 0.326, p=0.032). Plate fixation was not independently associated with any other examined complications. CONCLUSIONS: We found no difference in 30-day postoperative complications between plate fixation and intramedullary nailing of isolated extra-articular tibia fractures with the exception of decreased postoperative transfusion requirements with plate fixation. We conclude that both procedures offer a similar short-term complication profile.

Radiographic study of the fifth metatarsal for optimal intramedullary screw fixation of Jones fracture.

BACKGROUND: Jones fractures occur in the relatively avascular metadiaphyseal junction of the fifth metatarsal (MT), which predisposes these fractures to delayed union and nonunion. Operative treatment with intramedullary (IM) screw fixation is recommended in certain cases. Incorrect screw selection can lead to refractures, nonunion, and cortical blowout fractures. A better understanding of the anatomy of the fifth MT could aid in preoperative planning, guide screw size selection, and minimize complications. METHODS: We retrospectively identified foot computed tomographic (CT) scans of 119 patients that met inclusion criteria. Using interactive 3-dimensional (3-D) models, the following measurements were calculated: MT length, "straight segment length" (distance from the base of the MT to the shaft curvature), and canal diameter. RESULTS: The diaphysis had a lateroplantar curvature where the medullary canal began to taper. The average straight segment length was 52 mm, and corresponded to 68% of the overall length of the MT from its proximal end. The medullary canal cross-section was elliptical rather than circular, with widest width in the sagittal plane and narrowest in coronal plane. The average coronal canal diameter at the isthmus was 5.0 mm. A coronal diameter greater than 4.5 mm at the isthmus was present in 81% of males and 74% of females. CONCLUSION: To our knowledge, this is the first anatomic description of the fifth metatarsal based on 3-D imaging. Excessive screw length could be avoided by keeping screw length less than 68% of the length of the fifth metatarsal. A greater than 4.5 mm diameter screw might be needed to provide adequate fixation for most study patients since the isthmus of the medullary canal for most were greater than 4.5 mm. CLINICAL RELEVANCE: Our results provide an improved understanding of the fifth metatarsal anatomy to guide screw diameter and length selection to maximize screw fixation and minimize complications.

Treatment of peroneal nerve injuries with simultaneous tendon transfer and nerve exploration.

BACKGROUND: Common peroneal nerve palsy leading to foot drop is difficult to manage and has historically been treated with extended bracing with expectant waiting for return of nerve function. Peroneal nerve exploration has traditionally been avoided except in cases of known traumatic or iatrogenic injury, with tendon transfers being performed in a delayed fashion after exhausting conservative treatment. We present a new strategy for management of foot drop with nerve exploration and concomitant tendon transfer. METHOD: We retrospectively reviewed a series of 12 patients with peroneal nerve palsies that were treated with tendon transfer from 2005 to 2011. Of these patients, seven were treated with simultaneous peroneal nerve exploration and repair at the time of tendon transfer. RESULTS: Patients with both nerve repair and tendon transfer had superior functional results with active dorsiflexion in all patients, compared to dorsiflexion in 40% of patients treated with tendon transfers alone. Additionally, 57% of patients treated with nerve repair and tendon transfer were able to achieve enough function to return to running, compared to 20% in patients with tendon transfer alone. No patient had full return of native motor function resulting in excessive dorsiflexion strength. CONCLUSION: The results of our limited case series for this rare condition indicate that simultaneous nerve repair and tendon transfer showed no detrimental results and may provide improved function over tendon transfer alone.

Evaluation of posterior malleolar fractures and the posterior pilon variant in operatively treated ankle fractures.

BACKGROUND: Substantial attention has recently been placed on fractures of the posterior malleolus. Fracture extension to the posteromedial rim ("posterior pilon variant") may result in articular incongruity and talar subluxation. Current classification systems fail to account for these fractures. The relative frequency of this fracture, its associated patient characteristics, and the reliability of its diagnosis have never been reported in such a large series. METHODS: We retrospectively identified 270 patients who met our inclusion criteria. Basic demographic data were collected. The fractures were classified according to Lauge-Hansen and AO/OTA. Additional radiographic data included whether the fracture involved the posterior malleolus and whether the fracture represented a posterior pilon variant. Univariate statistical methods, chi-square analysis, and interobserver reliability were assessed. RESULTS: The relative frequency of posterior malleolus fracture was 50%. The relative frequency of the posterior pilon variant was 20%. No significant difference was noted with respect to the frequency of posterior malleolar or posterior pilon variant between the subgroups of the AO/OTA and Lauge-Hansen classification systems when compared to the overall fracture distribution. Patients with posterior malleolar fractures and posterior pilon variants were significantly older. Females were significantly more likely than men to sustain posterior malleolar fractures and posterior pilon variants. Patients with diabetes trended toward a greater risk of both types of fractures. Interobserver reliability data revealed substantial agreement for posterior malleolar fractures and posterior pilon variants. CONCLUSION: These data represent the highest reported rate of posterior malleolar involvement in operatively treated ankle fractures and is the first to describe the percentage of the posterior pilon variant in such a large series. The interobserver reliability data demonstrate substantial agreement in identification of posterior malleolar fractures and the posterior pilon variant based on plain radiographs. Certain patient characteristics such as age, sex, and diabetes may be associated with these fractures. LEVEL OF EVIDENCE: Level III, retrospective cohort study.