Identifying Intra-Articular Pathology With Arthroscopy Prior to Open Ankle Fracture Fixation.

PURPOSE: To assess the prevalence of intra-articular findings with ankle arthroscopy in patients undergoing operative fixation for ankle fractures. METHODS: This is a retrospective review of ankle fractures that were treated with arthroscopy and open reduction and internal fixation by a single surgeon. Between August 2016 and July 2018, operative reports, office notes, and images were reviewed to identify intra-articular pathology and fracture type. An analysis was performed with regard to fracture type, presence and location of osteochondral lesions, loose-bodies, syndesmotic injury, and deltoid injury. RESULTS: Fifty-seven ankle fractures were identified that met inclusion criteria. In total, 84.2% of the fractures had intra-articular pathology, most commonly a syndesmotic injury followed by presence of intra-articular loose bodies and osteochondral defects. CONCLUSIONS: In our study, use of arthroscopy before open ankle fracture fixation identified intra-articular pathology in 84.2% of subjects. The most common pathology was syndesmotic injury. The addition of an arthroscopic assessment in patients with operatively treated ankle fractures may help improve treatment provided to patients during ankle fracture surgery. LEVEL OF EVIDENCE: Level 4 Therapeutic Case Series.

Anatomic relationship of the sural nerve when performing Achilles tendon repair using the percutaneous Achilles repair system, a cadaveric study.

BACKGROUND: Minimally invasive techniques for Achilles tendon repair are increasing due to reports of similar rerupture rates using open and percutaneous techniques with fewer wound complications and quicker recovery with percutaneous methods. The goal of this study was to investigate quantitatively the relationship and risk of injury to the sural nerve during Achilles tendon repair when using the Percutaneous Achilles Repair System (PARS) (Arthrex®, Naples, FL), by recording the distance between the passed needles and the sural nerve as well identifying any direct violation of the nerve with needle passage or nerve entrapment within the suture after the jig was removed. The hypothesis of the study is that the PARS technique can be performed safely and without significant risk of injury to the sural nerve. METHODS: A total of five needles were placed through the PARS jig in each of 10 lower extremity cadaveric specimens using the proximal portion after simulation of a midsubstance Achilles tendon rupture. Careful dissection was performed to measure the distance of the sural nerve in relation to the passed needles. The sutures were then pulled out through the incision as the jig was removed from the proximal portion of the tendon and observation of the suture in relation to the tendon was documented. RESULTS: Of the 10 cadaveric specimens, none had violation of the sural nerve. Zero of the 50 (0%) needles directly punctured the sural nerve. In addition, upon retraction of the jig, all sutures were noted to reside within the tendon sheath with no entrapment of the sural nerve noted. CONCLUSION: This study demonstrated the variable course of the sural nerve and identifies the potential risk for sural nerve injury when using the PARS for Achilles tendon repair. However, this study provides additional evidence of safety from an anatomic standpoint that explains the outcomes demonstrated in the clinical trials. With this information the authors believe surgeons should feel comfortable they can replicate those outcomes while minimizing risk of sural nerve injury when the technique is used correctly.

Effectiveness of Nonoperative Treatment of the Symptomatic Accessory Navicular in Pediatric Patients.

Background: Initial management of symptomatic accessory navicular in pediatric patients is nonoperative. However, efficacy of nonoperative treatment has not been studied or established. If nonoperative treatment is frequently unsuccessful or does not give lasting pain relief, surgery could be offered as first line treatment. This study retrospectively reviewed outcomes of pediatric patients treated nonoperatively for symptomatic accessory naviculae in an effort to provide clinicians success rates for their discussion of treatment options with patients and their families. Methods: A retrospective analysis of pediatric patients diagnosed and treated nonoperatively for a symptomatic accessory navicular bone at Cincinnati Children's Hospital Medical Center between dates August 1st, 2006 and August 24th, 2016 was performed. Outcome measures consisted of complete pain relief, partial relief without operative intervention, or need for operative intervention. Radiographic imaging for each patient was also used to identify the type of accessory navicular and presence of concurrent pes planus. Results: A total of 169 patients were included, with 226 symptomatic accessory naviculae. Average age at diagnosis was 11.8 years, with majority females (78%). Type 2 accessory naviculae were most frequent (72.7%), with Type 1 and Type 3 in 9.7% and 17.4%, respectively. Average number of nonoperative trials was 2.1, with 28% experiencing complete pain relief, 30% requiring surgical intervention, and 41% that experienced partial pain relief and did not require surgical intervention, and were recommended as needed (PRN) follow-up based on clinical improvement. Of those that achieved complete pain relief, the average length of non-operative treatment was 8.0 months. Conclusions: The results of this study can be used by clinicians to frame discussions surrounding treatment options for symptomatic accessory navicular bones with both patients and their families.Level of Evidence: III.

Neuropsychological outcomes of childhood acute necrotizing encephalopathy.

Acute necrotizing encephalopathy (ANE) is a rare form of acute encephalopathy, predominantly occurring in childhood, which has a typical radiological phenotype including bilateral, symmetrical, diffusion-restricted lesions of the thalami; posterior putamen; cerebellum; and brainstem. To date, no study has systematically examined the long-term cognitive and psychological impact of ANE. The current study describes the neuropsychological outcomes of three paediatric cases of ANE, ranging from 18 months to 10 years post ANE. All three cases displayed inattention, fine motor difficulties and anxiety. Social difficulties were also reported in all cases. The severity of long-term impairment was associated with acute presentation, as well as convalescent neuroimaging. These findings highlight the need for detailed neuropsychological assessment and long-term rehabilitation.

Vocabulary skills of school-age children with acquired brain injury: an exploration of tiered word knowledge and naming errors.

BACKGROUND: Vocabulary deficits are the most frequently documented communication difficulty following childhood acquired brain injury (ABI). Given the adverse consequences of limited vocabulary on academic success, it is critical to identify the presence and nature of vocabulary impairments to provide effective intervention for children with ABI. METHOD: Eleven children (7;6-11;11) with moderate/severe ABI (>12 months post-injury) and individually matched typically developing (TD) controls completed an Australian adaptation of a vocabulary assessment based on a three-tiered framework: tier 1 (basic words), tier 2 (high-frequency, cross-curricular words), and tier 3 (curriculum-based words). Overall scores and tiered accuracy were compared at individual and group level. Type and frequency of expressive naming errors were also coded. RESULTS: In this pilot study, children with ABI demonstrated poorer overall scores than TD children. Equivalent accuracy was noted for tier 1 words and tier 2 receptive words. However, significantly poorer accuracy was noted in the ABI group for tier 2 expressive words and all tier 3 words. The majority of naming errors were semantic across both groups although TD participants showed a wider distribution of error types. CONCLUSIONS: Findings support the use of tier 2 and 3 vocabulary as intervention targets in this population within education contexts and speech pathology settings.

Clinical results after treatment for bidirectional patellar subluxation: Minimum 2-years follow-up.

BACKGROUND: We describe the preliminary clinical results of a patellar stabilization technique to treat bidirectional patellar subluxation (BPS). METHODS: Patients: six patients (one male, five females; mean age 30.2years) underwent this procedure with a minimum of 24months follow-up. Patients were assessed for clinical instability, patellar complications, and need for revision surgery. Patient functional outcomes were evaluated using the criteria of Crosby and Insall and the Kujala Anterior Knee Pain Scale at the time of final follow-up. Patient satisfaction was assessed using a subjective questionnaire. OPERATIVE TECHNIQUE: A semitendinosus tendon autograft is coursed through a transverse tunnel in the distal quadriceps tendon. The medial and lateral aspects of the graft are passed from the quadriceps tendon within subfascial tunnels to the MPFL attachment site and lateral epicondyle, respectively. The graft is fixed in 60° of knee flexion with suture anchors. RESULTS: Surgery for recurrent instability was performed in one case. There were no cases of infection, quadriceps tendon rupture, or patella fracture. At average follow-up of 29.2months (range, 24 to 38months), outcomes were good to excellent in 4/6 of cases. Kujala scores improved significantly from 33.3 (range, three to 58) preoperatively to 70.8 (range, 39 to 96) postoperatively (p<0.05). 5/6 patients reported being satisfied to completely satisfied with their result. CONCLUSION: Patients undergoing bidirectional patellar stabilization with a single tendon graft showed improved postoperative functional scores. The technique is successful in reducing pain and restoring bidirectional patellar stability at 2-years follow-up. LEVEL OF EVIDENCE: IV, retrospective case series.