Relationship Between Tibiotalar Joint Space and Ankle Function Following Ankle Surgery.

BACKGROUND: Joint-preserving procedures of the ankle may postpone the need for ankle arthrodesis (AA) or total ankle replacement (TAR). The challenge for the surgeon is to determine which patients may benefit from these joint-preserving procedures. We hypothesized that patents with less than 2 mm of ankle joint space on preoperative radiographs would report inferior outcomes following joint-preserving surgery compared with those with 2 mm or greater joint space. METHODS: Patients 18 years of age or older treated with joint-preserving ankle surgery with a minimum of 2 years of follow-up were considered for study inclusion. The ankle joint space was measured on standardized weightbearing preoperative radiographs. At follow-up, patients completed questionnaires including the Foot and Ankle Ability Measure (FAAM) Activities of Daily Living (ADL) and Sports subscales, the Short Form-12 (SF-12) Physical Component Summary and Mental Component Summary, the Tegner Activity Scale, and satisfaction with outcome. RESULTS: A total of 251 patients were included in the study. Forty-three patients had an ankle joint space of less than 2 mm. Compared with the 208 patients with an ankle joint space of 2 mm or greater, they had inferior FAAM ADL, FAAM Sports, and SF-12 Physical Component Summary scores (P = .001, P = .001, and P = .006, respectively). Additionally, a statistically significant positive correlation between joint space distance and the FAAM ADL (P = .012, r = 0.158), FAAM Sports (P < .001, r = 0.301), and SF-12 Physical Component Summary (P < .010, r = 0.163) scores was found. CONCLUSION: Patients with a preoperatively narrowed ankle joint space of less than 2 mm had significantly lower outcome scores following joint-preserving ankle surgery compared with patients with preserved ankle joint space. These results may assist clinicians in selecting patients who may benefit from ankle joint-preserving procedures, as well as counseling patients with a narrowed ankle joint space regarding expected outcome after joint-preserving ankle surgery. LEVEL OF EVIDENCE: Level II, prognostic comparative study.

Safety and Communication in the Operating Room: A Safety Questionnaire After the Implementation of a Blood-Borne Pathogen Exposure Checkpoint in the Surgical Safety Checklist Preprocedure Time-Out.

INTRODUCTION: The Surgical Safety Checklist (SSC) decreases patient morbidity and mortality and improves operating room (OR) communication. However, the SSC does not currently include any discussion on employee safety. One institution has implemented a blood-borne pathogen exposure (BBPE) checkpoint in the SSC in order to improve employee safety and to further improve communication. The aim of this study was to determine if the implementation of a BBPE checkpoint improved caregiver safety and communication in the OR. METHODS: This was a multidisciplinary prospective survey study in which an anonymous questionnaire was distributed to all OR personnel who handle sharps. Survey responses were analyzed for demographics and BBPE safety attitudes. The frequency of reported BBPE incidents collected from quality improvement data 12 months before and after the implementation of the BBPE checkpoint were reviewed. RESULTS: Caregivers feel safer in the OR with the BBPE checkpoint (p < 0.001). Communication was improved. Compliance in trauma surgeries was less than elective. Reported BBPE incidents were significantly decreased based on quality improvement data (p = 0.045). CONCLUSION: The BBPE checkpoint was implemented in the SSC at one institution in order to emphasize employee safety and improve communication. The results shed light on the attitudes of OR personnel by suggesting an improvement in safety and communication. In addition, there has been decrease of reported BBPE incidents among OR personnel. Universal implementation of a BBPE checkpoint could improve provider safety and communication in all ORs.

Utilization of Transtibial Centralization Suture Best Minimizes Extrusion and Restores Tibiofemoral Contact Mechanics for Anatomic Medial Meniscal Root Repairs in a Cadaveric Model.

BACKGROUND: Although posterior medial meniscal root (PMMR) repairs are often successful, postoperative meniscal extrusion after a root repair has been identified as a potential clinical problem. PURPOSE/HYPOTHESIS: The purpose was to quantitatively evaluate the tibiofemoral contact mechanics and extent of meniscal extrusion after a PMMR repair. It was hypothesized that the addition of a centralization suture (into the posterior medial tibial plateau) would help restore normal joint load-bearing characteristics and restore the native amount of meniscal extrusion after a root tear. Furthermore, we hypothesized that the amount of meniscal extrusion would be greatest in loaded and flexed knees when measured at the posterior border of the medial collateral ligament (MCL). STUDY DESIGN: Controlled laboratory study. METHODS: Meniscal extrusion and tibiofemoral contact mechanics were measured using 3-dimensional digitization and pressure sensors in 10 nonpaired, human cadaveric knees. The PMMR of each knee was tested under 6 states: (1) intact; (2) type 2A PMMR tear; (3) anatomic transtibial pull-out root repair; (4) anatomic transtibial pull-out repair with centralization; (5) nonanatomic transtibial pull-out repair; and (6) nonanatomic transtibial pull-out repair with centralization, with randomization of the order of conditions 3 and 4, and 5 and 6. The testing protocol loaded knees with a 1000-N axial compressive force at 4 flexion angles (0°, 30°, 60°, 90°) in each state. Meniscal extrusion was measured with a 3-dimensional coordinate digitizer at 0° and 90° in both the loaded and unloaded states and calculated from the difference from the articular margin of the tibia to the periphery of the meniscus. Peak contact pressure, contact area, and total contact pressure were also recorded for all states at all flexion angles. Statistical analysis investigated the independent effects of flexion, state, and loading using 3 distinct 2-factor models. RESULTS: Differences in the contact mechanics between repair techniques were most notable at higher flexion angles, demonstrating significantly higher average and peak contact pressures for nonanatomic repair states when compared with anatomic repairs with and without centralization (all P < .05). In unloaded knees at full extension, the magnitude of medial meniscal extrusion was significantly higher at the posterior border of the MCL compared with the posterior medial tibia ( P < .001) and adjacent to the root attachment on the tibia locations ( P < .001). Both anatomic repair states had no significant difference in the degree of extrusion when compared with the intact state. CONCLUSION: The anatomic transtibial pull-out root repair and the anatomic transtibial pull-out root repair with centralization techniques best restored contact mechanics of the knee and meniscal extrusion when compared with root tear and nonanatomic repair states at time zero. There were no significant differences in contact pressure or magnitude of extrusion between the anatomic repair state and the anatomic repair with centralization state. We found that extrusion is best measured in the coronal plane at the posterior border of the MCL for unloaded knees. However, the degree of extrusion increased as the knee was loaded and flexed to 90°. CLINICAL RELEVANCE: When there are concerns about meniscal extrusion with a medial meniscal root repair, the addition of a centralization suture may be beneficial for patients in reducing pathologic meniscal extrusion and restoring joint contact mechanics.

Posterior Tibial Slope and Risk of Posterior Cruciate Ligament Injury.

BACKGROUND: Recent biomechanical studies have identified sagittal plane posterior tibial slope as a potential risk factor for posterior cruciate ligament (PCL) injury because of its effects on the kinematics of the native and surgically treated knee. However, the literature lacks clinical correlation between primary PCL injuries and decreased posterior tibial slope. PURPOSE/HYPOTHESIS: The purpose of this study was to retrospectively compare the amount of posterior tibial slope between patients with PCL injuries and age/sex-matched controls with intact PCLs. It was hypothesized that patients with PCL injuries would have a significantly decreased amount of posterior tibial slope when compared with patients without PCL injuries. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Patients who underwent primary PCL reconstruction without anterior cruciate ligament injury between 2010 and 2017 by a single surgeon were retrospectively analyzed. Measurements of posterior tibial slope were performed with lateral radiographs of PCL-injured knees and matched controls without clinical or magnetic resonance imaging evidence of ligamentous injury. Mean values of posterior tibial slope were compared between the groups. Inter- and intrarater agreement was assessed for the tibial slope measurement technique via a 2-way random effects model to calculate the intraclass correlation coefficient (ICC). RESULTS: In sum, 104 patients with PCL tears met the inclusion criteria, and 104 controls were matched according to age and sex. There were no significant differences in age ( P = .166), sex ( P = .345), or body mass index ( P = .424) between the PCL-injured and control groups. Of the PCL tear cohort, 91 patients (87.5%) sustained a contact mechanism of injury, while 13 (12.5%) reported a noncontact mechanism of injury. The mean ± SD posterior tibial slopes were 5.7°± 2.1° (95% CI, 5.3°-6.1°) and 8.6°± 2.2° (95% CI, 8.1°-9.0°) for the PCL-injured and matched control groups, respectively ( P < .0001). Subgroup analysis of the PCL-injured knees according to mechanism of injury demonstrated significant differences in posterior tibial slope between noncontact (4.6°± 1.8°) and contact (6.2°± 2.2°) injuries for all patients with PCL tears ( P = .013) and among patients with isolated PCL tears ( P = .003). The tibial slope measurement technique was highly reliable, with an ICC of 0.852 for interrater reliability and an ICC of 0.872 for intrarater reliability. CONCLUSION: A decreased posterior tibial slope was associated with patients with PCL tears as compared with age- and sex-matched controls with intact PCLs. Decreased tibial slope appears to be a risk factor for primary PCL injury. However, further clinical research is needed to assess if decreased posterior tibial slope affects posterior knee stability and outcomes after PCL reconstruction.

Knotless Suture Anchor Repair of Anterolateral Meniscus Root After Iatrogenic Injury.

In recent years there has been increased attention on preserving the menisci because they perform vital roles in maintaining knee joint homeostasis. The anterolateral (AL) meniscal root is particularly vulnerable during anterior cruciate ligament reconstruction. When the AL root is iatrogenically injured, it is imperative that it is repaired in a timely fashion to prevent early-onset osteoarthritis. In this article we outline our knotless suture anchor repair for AL root tears.

Biomechanical Analysis of Tibial Tuberosity Medialization and Medial Patellofemoral Ligament Reconstruction.

Biomechanical studies are commonly performed to evaluate the influence of medial patellofemoral ligament (MPFL) reconstruction and tibial tuberosity medialization on patellar tracking and patellofemoral contact pressures. The most common method is in vitro simulation of knee function, but computational simulation of knee function and computational reconstruction of in vivo motion can also be utilized. The current review of the biomechanical literature indicates that MPFL reconstruction and tibial tuberosity medialization reduce lateral patellar tracking. Decreased lateral patellofemoral contact pressures have also been noted. For MPFL reconstruction, the most commonly noted biomechanical concerns are graft overtensioning and nonanatomic attachment on the femur leading to overconstraint of the patella and elevated medial contact pressures. For tuberosity medialization, the influence of altered tibiofemoral kinematics on postoperative function is unknown. Future biomechanical studies should emphasize inclusion of anatomic features and tracking patterns related to patellar instability, with comparison between the surgical approaches for continued development of treatment guidelines.

Locating the sural nerve during calcaneal (Achilles) tendon repair with confidence: a cadaveric study with clinical applications.

The sural nerve is at risk of iatrogenic injury even during minimally invasive operative procedures to repair the calcaneal (Achilles) tendon. Through 107 cadaveric leg dissections, the data derived from the present study was used to develop a regression equation that will enable surgeons to estimate the intersection point at which the sural nerve crosses the lateral border of the Achilles tendon, an important surgical landmark. In most cases, the sural nerve crossed the lateral border of the Achilles tendon 8 to 10 cm proximal to the superior border of the calcaneal tuberosity. By simply measuring the leg length of the patient (from the base of the heel to the flexor crease of the popliteal fossa), surgeons can approximate the location of this intersection point with an interval length of 0.68 to 1.80 cm, with 90% confidence, or 0.82 to 2.15 cm, with 95% confidence. For example, for a patient with a lower leg length of 47.0 cm, the mean measurement in the present study, a surgeon can be 90% confident that the sural nerve will cross the lateral border of the Achilles tendon 8.28 to 8.96 cm (interval width of 0.68 cm) proximal to the calcaneal tuberosity. Currently, ultrasound and clinical techniques have been implemented to approximate the location of the sural nerve. The results of the present study offer surgeons another method, that is less intensive, to locate reliably and subsequently avoid damage to the sural nerve during calcaneal (Achilles) tendon repair and other procedures of the posterolateral leg and ankle.

Clinical implications of novel variants of the fibularis (peroneus) quartus muscle inserting onto the cuboid bone: peroneocuboideus and peroneocalcaneocuboideus.

Two variants of the fibularis (peroneus) quartus muscle were identified and photographed in the legs of a 70-year-old white male cadaver. A rare peroneocuboideus (fibulocuboideus) muscle (as described by Chudzinski) and a novel peroneocalcaneocuboideus (fibulocalcaneocuboideus) muscle was found in the right and left leg, respectively. The latter muscle has not been previously reported and was termed "peroneocalcaneocuboideus" on the basis of its origin and insertions. Also, the distal attachment of both muscles inserted onto the distal lip of the peroneal sulcus of the cuboid bone, which differs from the historical data. The insertion of the peroneocuboideus muscle was previously described as being at the tuberosity of the cuboid bone or, simply, the lateral surface of the cuboid. Therefore, the present case study provides the first gross anatomic photographs of these variant leg muscles along their entire length, identifies a novel fibularis quartus variant, and describes a new insertion site for the peroneocuboideus muscle. Throughout our report, the historical data are reviewed to list the prevalence and describe the clinical implications of the fibularis quartus muscle and its variants. The presence of variant fibularis quartus muscles has been known to cause lateral ankle pain and stenosis, ankle instability, fibular tenosynovitis, subluxation of the fibular (peroneal) tendons, and longitudinal splitting of the fibularis brevis tendon in radiologic and case studies. Therefore, surgeons, radiologists, and clinicians should be aware of these variant muscles when considering various diagnoses, interpreting radiographs, and pursuing surgical intervention to relieve lateral ankle pathologic features.

Cervical variations of the phrenic nerve.

OBJECTIVES/HYPOTHESIS: Selective reinnervation of the posterior cricoarytenoid muscle with a single phrenic nerve rootlet has been shown to restore physiologic motion in animal models. However, clinical translation of this work is challenged by the limited knowledge of the cervical anatomy of the phrenic nerve. STUDY DESIGN: Prospective collaborative study. METHODS: Dissection of 111 cadaveric necks (88 embalmed and 23 unembalmed) from 56 cadavers. RESULTS: The mean (standard deviation) lengths of unembalmed cadaver C3, C4, and C5 nerve rootlets were 3.9 (2.4), 3.6 (2.6), and 0.5 (0.8) cm, respectively. Embalmed cadavers had shorter C3 and C4 phrenic nerve rootlet lengths than unembalmed cadavers (P = .02 and P = .03, respectively). There was no difference in mean nerve rootlet length based on sex, body height or weight, or side of dissection. A total of eight unique phrenic nerve rootlet patterns were identified. The most common pattern consisted of phrenic with single C3 and C4 rootlets with an immeasurable C5 rootlet, which was present in 30 of 111 (26%) of the necks. The classic three branching pattern of single C3, C4, and C5 rootlets was found in 25 of 111 (22%) of the necks. Six of 111 (5%) of the dissections displayed accessory phrenic nerves arising from the C3, C4, or C5 anterior rami. A χ(2) analysis showed no difference between side or sex and frequency of pattern. CONCLUSIONS: The present study demonstrates the wide variability within the cervical anatomy of the phrenic nerve.

Spontaneous bacterial seeding of a biceps hematoma.

A 19-year-old male construction worker presented with an injury to his left upper arm after lifting a heavy pipe. He reported an acute onset of sharp pain followed by swelling, warmth, and weakness with elbow flexion. The diagnosis of a distal biceps tendon rupture was made and elective repair was scheduled. Seventy-two hours later, the patient presented with a spontaneous draining wound on his anterior distal humerus. The wound was draining thick purulent material. The patient underwent surgery for irrigation and debridement of his abscess. Nearly 500 cc of hematoma and purulent fluid were evacuated. A large tear of both the biceps and brachialis muscle bellies were found. Cultures were obtained that revealed the infecting organism to be Streptococcus intermedius. Human immunodeficiency virus and hepatitis-C virus testing were negative, and no history, signs, or symptoms of any cause of underlying immunodeficiency were detected. No signs or history of drug use were present. He was discharged home on culture-specific oral antibiotics. At 4-month postoperative follow-up, the patient reported no pain or limitations. He has returned to full duty at his job. Elbow range of motion was measured from 7° to 150° of flexion. Strength of elbow flexion and extension was symmetric to the uninjured side. Pronation and supination of the forearm was symmetric on both sides. He has been released from scheduled follow-up and will be seen again on an as-needed basis.