Anatomy of the Flexor Hallucis Longus and Its Relationship With Hallux Valgus: A Cadaveric Study.

BACKGROUND: Hallux valgus (HV) is a complex deformity, with many associated risk factors. The flexor hallucis longus (FHL) tendon is a dynamic and potentially deforming force as it bowstrings laterally with HV. We hypothesized that FHL is more laterally inserted in the distal phalanx in cadavers with HV; therefore, it might be also a primary destabilizing force. We aim to compare the FHL distal insertion morphology and its relationship with osseous structures in cadavers with and without HV. METHODS: Sixteen cadaver specimens, 8 with HV and 8 without (N-HV) were dissected. We evaluated FHL distal morphology in terms of its insertional footprint location and FHL long-axis position in relation to osseous anatomy. RESULTS: Both the HV and N-HV groups displayed a laterally inserted footprint at the distal phalanx, with the HV group exhibiting median lateral translation of the footprint 6% greater than the N-HV group (P < .01). Both groups also demonstrated a laterally displaced position for the FHL long axis. The median FHL long axis for HV vs N-HV specimens 1 cm proximal to the IP joint was 9% more laterally displaced from the midaxis (P < .01), and at 1 cm proximal to the MTP joint was measured to be 15% more laterally displaced from the midaxis (P < .01). CONCLUSION: FHL demonstrated an eccentric position in terms of insertion and trajectory in both the HV and N-HV groups, with greater lateralization in specimens exhibiting HV deformity. This eccentricity potentially creates a greater deforming force vector contributing to the development of HV. CLINICAL RELEVANCE: The etiology and progression of HV deformity may include a lateralized insertion of the FHL tendon. Treatment implications remain unknown at this time.

Satisfacción personal y percepción de éxito en mujeres en traumatología: factores determinantes en la elección de la especialidad y desarrollo profesional / Personal satisfaction and perception of success among female orntthopedic surgeons: key factors in the choice of specialty and professional development

Históricamente, las médicas han sido asociadas a especialidades determinadas. En los últimos años, estos estereotipos han sido lentamente revertidos con mayor participación de la mujer en especialidades quirúrgicas. En el proceso de aprendizaje se sabe la importancia que tienen los modelos y mentores. Buscamos evaluar el grado de satisfacción y el éxito profesional de las mujeres en Traumatología, y qué factores cumplieron un rol positivo en la decisión de optar por ella.Se encuestó a 108 mujeres dedicadas a la Traumatología, y se evaluaron las influencias positivas y los mentores como modelo en la toma de decisión por la especialidad y los grados de satisfacción personal y profesional.Pese a una mayor percepción de dificultades en lograr el objetivo, destacan los altos grados de satisfacción profesional y personal de las mujeres en Traumatología: 95% refirió haber elegido la especialidad correcta, 100% afirmó que las dificultades se compensan con los resultados obtenidos, y 96% volvería a elegir la misma especialidad. En relación con la percepción de éxito, 73% se considera exitosa en su vida profesional, y en la vida personal, 85%.Muy relevante en la toma de decisión por la especialidad es el rol que cumplen docentes, mentores, y el gusto por la cirugía y los deportes. Un 84% recibió alguna influencia positiva, 61% tuvo como modelo en su formación una traumatóloga, y un 98% recomendaría a otras mujeres en período de formación que se dedicaran a la Traumatología.Las estrategias de incremento de la participación femenina en la especialidad pudiesen orientarse a fomentar modelos femeninos durante el aprendizaje.

Historically, female doctors have been associated with certain specialties. In recent years, these stereotypes have been slowly reversed with an increased participation of women in surgical specialties. The importance of models and mentors in the learning process is known. We seek to evaluate the level of professional satisfaction and success of women in Traumatology, as well as the factors that may have played a positive role in the decision to pursue this specialty. We surveyed 108 women working in Traumatology and evaluated the positive influences and mentors as models in the decision-making regarding the specialty and the degrees of personal and professional satisfaction. Despite a greater perception of difficulties in achieving the purpose, the high degrees of professional and personal satisfaction of women in Traumatology stands out: 95% reported having chosen the correct specialty, 100% stated that the difficulties are offset by the results obtained, and 96% would choose the same specialty again. Regarding the perception of success, 73% consider themselves successful in their occupation, and 85% consider themselves successful in their personal lives. The role played by teachers, mentors, as well as an interest in surgery and sports are very relevant in choosing the specialty. In total, 84% of the sample received some positive influence 61% had a female traumatologist as a model during their training, and 98% would recommend other women in training to dedicate themselves to Traumatology. The strategies to increase female participation in the specialty could be aimed at promoting female role models during learning.

Posterior pilon fracture: Epidemiology and surgical technique.

OBJECTIVES: To review a case series of patients with posterior pilon variant fracture using a novel approach, focusing on demographic data, injury pattern, surgical results based on computed tomography (CT) scan, and short-term complications. DESIGN: Consecutive case series. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Twenty-five patients with posterior pilon fracture. INTERVENTION: Posterior pilon fracture open reduction and internal fixation. MAIN OUTCOME MEASUREMENTS: Parameters measured included age, sex, type of fracture, surgical technique, anatomical reduction, and complications. RESULTS: Twenty-five patients sustained a posterior pilon fracture, accounting for 13.4% of all operatively treated ankle fractures with median follow-up of 21.7 months. The average age of patients was 42 years (22-62); 19/25 (76%) were female, and 6/25 (24%) were male. A modified posteromedial approach was used in 18/25 (72%) patients. Persistent syndesmotic instability was present in 11/25 (44%) patients after posterior malleolar stabilization. Quality of reduction was assessed under CT scan in 19 patients, with 15/19 (78.9%) having anatomic reduction. We report 2/25 (8%) patients with early wound problems and 7/25 (20%) with short-term complications during follow-up. CONCLUSION: Posterior pilon variant fracture appears to be less common than previously reported. Most fractures can be satisfactorily treated through a modified posteromedial approach. Albeit obtaining posterior malleolar fracture rigid fixation, syndesmotic instability was more prevalent than expected. The short-term complication rate was low. LEVEL OF EVIDENCE: Therapeutic level IV.

Platelet-rich plasma use in anterior cruciate ligament surgery: systematic review of the literature.

PURPOSE: To systematically review the current literature for evidence that would substantiate the use of platelet-rich plasma (PRP) in the treatment of anterior cruciate ligament (ACL) ruptures. METHODS: We performed a systematic search in PubMed and Embase of studies written in the English and Spanish languages that compared the use of PRP with a control group in patients with ACL injuries assessing graft-to-bone healing, graft maturation, and/or clinical outcomes and were randomized controlled trials or prospective cohort studies. RESULTS: Eleven studies fulfilled the inclusion criteria, comprising 516 patients (266 ACL reconstructions using PRP and 250 ACL reconstructions without PRP). Six studies reported a statistically significant difference (4 studies) or tendency toward faster graft maturation in the platelet group (2 studies). One study found no differences. Regarding tunnel healing/widening, 1 study showed faster healing in the PRP group and 5 studies showed no differences between the 2 groups. Considering clinical outcomes, 1 study showed better clinical outcomes with PRP use and 5 studies showed no benefits with the use of PRP. CONCLUSIONS: Concerning ACL graft maturation, there is promising evidence that the addition of PRP could be a synergic factor in acquiring maturity more quickly than grafts with no PRP, with the clinical implication of this remaining unclear. Regarding tunnel healing, it appears that there is not an improvement with the addition of PRP. There is no proof that clinical outcomes of ACL surgery are enhanced by the use of PRP. LEVEL OF EVIDENCE: Level III, systematic review of Level I through III studies.

Biomechanical evaluation of various suture configurations in side-to-side tenorrhaphy.

BACKGROUND: Side-to-side tenorrhaphy is increasingly used, but its mechanical performance has not been studied. METHODS: Two porcine flexor digitorum tendon segments of equal length (8 cm) and thickness (1 cm) were placed side by side. Eight tenorrhaphies (involving sixteen tendons) were performed with each of four suture techniques (running locked, simple eight, vertical mattress, and pulley suture). The resulting constructs underwent cyclic loading on a tensile testing machine, followed by monotonically increasing tensile load if failure during cyclic loading did not occur. Clamps secured the tendons on each side of the repair, and specimens were mounted vertically. Cyclic loading varied between 15 N and 35 N, with a distension rate of 1 mm/sec. Cyclic loading strength was determined by applying a force of 70 N. The cause of failure and tendon distension during loading were recorded. RESULTS: All failures occurred in the monotonic loading phase and resulted from tendon stripping. No suture or knot failure was observed. The mean loads resisted by the configurations ranged from 138 to 398 N. The mean load to failure, maximum load resisted prior to 1 cm of distension, and load resisted at 1 cm of distension were significantly lower for the vertical mattress suture group than for any of the other three groups (p < 0.031). CONCLUSIONS: All four groups sustained loads well above the physiologic loads expected to occur in tendons in the foot and ankle (e.g., in tendon transfer for tibialis posterior tendon insufficiency). None of the four side-to-side configurations distended appreciably during the cyclic loading phase. The vertical mattress suture configuration appeared to be weaker than the other configurations. CLINICAL RELEVANCE: For surgeons who advocate immediate loading or motion of a side-to-side tendon repair, a pulley, running locked, or simple eight suture technique appears to provide a larger safety margin compared with a vertical mattress suture technique.