Anatomic Structures at Risk During Posterior to Anterior Percutaneous Screw Fixation of Posterior Malleolar Fractures: A Cadaveric Study.

Background. There are no established guidelines for fixation of posterior malleolus fractures (PMFs). However, fixation of PMFs appears to be increasing with growing evidence demonstrating benefits for stability, alignment, and early functional outcomes. The purpose of this study was to determine the risk to anatomic structures utilizing a percutaneous technique for posterior to anterior (PA) screw fixation of PMFs. Methods. Percutaneous PA screw placement was carried out on 10 fresh frozen cadaveric ankles followed by dissection to identify soft tissue and neurovascular structures at risk. The distance from the guidewire to each anatomic structure of interest was measured. The correlation between the mean distances from the guidewire to each structure was calculated. Results. The sural nerve was directly transected in 1/10 specimens (10%) and in contact with the wire in a second specimen (10%). There was a significant correlation between the proximity of the guidewire to the apex of Volkmann's tubercle and its proximity to the sural nerve. The flexor hallucis longus (FHL) muscle belly was perforated by the guidewire 40% of the time but was not tethered or entrapped by the screw. Conclusions. Percutaneous PA screw placement is a safe technique which can be improved with several modifications. A mini-open technique is recommended to protect the sural nerve. There may be potential for tethering of the FHL with use of a washer or large screw head. Risk to the anterior and posterior neurovascular bundles is minimal.Levels of Evidence: Level V.

Distal femoral valgus cut angles unreliable in total knee arthroplasty.

We hypothesized that valgus distal femoral cut angle made using a conventional cutting guide would be reproducible in a Sawbone model, regardless of training level. 3°, 5°, or 7° valgus cuts were made on lower extremity Sawbone specimens and were measured with radiographic imaging. 66 patient radiographs were also analyzed to compare pre and post-operative femoral cut angles, and VR12 measurements from each patient were collected. All femoral cuts deviated significantly from target cuts. Also, pre-TKA valgus angles showed no correlation with the angles post-TKA, and final cut angle did not correlate with functional outcomes at 1 year post-surgery.

Tibial Stress Fracture Following Ankle Arthrodesis.

BACKGROUND: End-stage ankle arthritis is frequently treated with either tibiotalar or tibiotalocalcaneal (TTC) arthrodesis, but the inherent loss of accommodative motion increases mechanical load across the distal tibia. Rarely, patients can go on to develop a stress fracture of the distal tibia without any antecedent traumatic event. The purpose of this study was to determine the incidence of tibial stress fracture after ankle arthrodesis, highlight any related risk factors, and identify the effectiveness of treatment strategies and their healing potential. METHODS: A retrospective chart review was performed at 2 large academic medical centers to identify patients who had undergone ankle arthrodesis and subsequently developed a stress fracture of the tibia. Any patient with a tibial stress fracture before ankle arthrodesis, or with a nontibial stress fracture, was excluded from the study. RESULTS: A total of 15 out of 1046 ankle fusion patients (1.4%) developed a tibial stress fracture at a mean time of 42 ± 82 months (range, 3-300 months) following the index procedure. The index procedure for these 15 patients who went on to subsequently develop stress fractures included isolated ankle arthrodesis (n = 8), ankle arthrodesis after successful subtalar fusion (n = 2), primary TTC arthrodesis (n = 2), and ankle arthrodesis subsequent to successful subtalar fusion with resultant ankle nonunion requiring revision TTC nailing (n = 3). Four patients had undergone fibular osteotomy with subsequent onlay strut fusion, and 5 had undergone complete resection of the lateral malleolus. Stress fracture location was found to be at the level of the fibular osteotomy in 2 patients and at the proximal end of an existing or removed implant in 9. Fourteen of the 15 patients had a nondisplaced stress fracture and were initially treated with immobilization and activity modification. Of these, 3 failed to improve with nonoperative treatment and subsequently underwent operative fixation (intramedullary nail in 2; plate fixation in 1). Only 1 of the 15 patients presented with a displaced fracture and underwent immediate plate fixation. All patients reported pain improvement and were ultimately healed at final follow-up. CONCLUSION: In this case series review, we found a 1.4% incidence of tibial stress fracture after ankle arthrodesis, and both hardware transition points and a fibular resection or osteotomy appear to be risk factors. Operative intervention was required in approximately 25% of this population, but the majority of tibial stress fractures following ankle fusion were successfully treated nonoperatively, and ultimately all healed. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Limited Open Achilles Tendon Repair in Supine Position With Modified Ring Forceps: A Technique Tip.

We present a modification to prior Achilles tendon repair techniques that utilizes readily available noncommercial instrumentation, mini-open incisions, and supine positioning, thus maximizing surgical efficiencies and reducing complications. In our experience, this is a safe and effective technique that minimizes anesthetic requirements and operating room time. Levels of Evidence: Level V, expert opinion.

Deep Infections After Syndesmotic Fixation With a Suture Button Device.

Suture button devices such as the TightRope (Arthrex, Naples, Florida) have been increasingly used for syndesmotic fixation of ankle fractures. Despite proposed advantages, prior studies have shown equivalent outcomes, with a theoretical decreased need for removal of hardware. Complications of suture button fixation of syndesmotic instability may be underreported and include lateral suture knot inflammation with or without granuloma formation, infection, aseptic osteolysis with widening of the tibial drill tunnels, heterotopic ossification, and osteomyelitis. In this case series, the authors review the current literature and describe 3 patients with TightRope fixation for syndesmotic instability who developed deep infection. The authors believe that braided suture within suture button devices may provide an environment conducive to the propagation of infection across the syndesmotic fixation tract. Evidence of suture button migration or osteolysis of the TightRope tract should prompt an infectious workup and removal of hardware. If there is concern for infection associated with the TightRope, the authors recommend removing both metallic buttons and the entirety of the suture to prevent harboring a nidus for further infection. [Orthopedics. 2017; 40(3):e541-e545.].

Orthopaedic Surgery Residency: Perspectives of Applicants and Program Directors on Medical Student Away Rotations.

INTRODUCTION: Senior medical students frequently rotate at orthopaedic residency programs away from their home medical schools. However, to our knowledge, the perspective of program directors (PDs) and applicants on the value, objectives, and costs of these rotations has not been studied. METHODS: Surveys evaluating the frequency, costs, benefits, and objectives of away rotations were distributed to all orthopaedic residency PDs in the United States and applicants in the 2014-2015 Match cycle. Data analysis was conducted to perform inferential and descriptive statistics; comparisons were made between and among PD and applicant groups using two-tailed means Student t-test and analysis of variance. RESULTS: A total of 74 PD (46.0%) and 524 applicant (49.3%) responses were obtained from a national distribution. Applicants completed an average of 2.4 away rotations, with an average cost of $2,799. When stratified on self-reported likelihood of Matching, there were no substantial differences in the total number of rotations performed. The only marked differences between these groups were the United States Medical Licensing Examination Step 1 score and the number of applications to residency programs. PDs reported that significantly fewer rotations should be allowed, whereas applicants suggested higher limits (2.42 rotations versus 6.24, P < 0.001). PDs and applicants had similar perspectives on the value of away rotations; both groups reported more value in finding a "good fit" and making a good impression at the program and placed less value on the educational impact. DISCUSSION: The value of orthopaedic away rotations appears more utilitarian than educational for both PDs and applicants. Rotations are performed regardless of perceived likelihood of Matching and are used by students and programs to identify a "good fit." Therefore, given the portion of an academic year that is spent on orthopaedic rotations, findings showing perceived low educational value and marked discrepancies between the expected number of rotations by PDs and applicants indicate that the current structure of away rotations may not be well aligned with the mission of undergraduate medical education. LEVEL OF EVIDENCE: V.

Initial review of the U.S. Navy's pressurized submarine escape training outcomes.

The U.S. Navy reinstituted pressurized submarine escape training (PSET) for submarine sailors in 2009 after a nearly 30-year absence. This training addresses escape from a disabled submarine at depth with the use of the Beaufort, Ltd. Mk 10 Submarine Escape and Immersion Equipment (SEIE) suit. Training is classified as "high-risk" due to previous U.S. and foreign navy experience with training-associated morbidity and mortality, particularly from diving-related illness. To reduce risk, medical screening procedures are performed. During the first 39 months of training, 7,025 students screened for PSET with 32% completing all phases, including two pressurized ascents. The most common reason for screening disqualification was presence of upper respiratory congestion. During training, middle ear barotrauma was responsible for 53% of attrition, primarily during the test of pressure.